Treatment of genotyped diabetic patients with dpp-iv inhibitors such as linagliptin

ABSTRACT

The present invention relates to methods for preventing or treating of metabolic disorders and related conditions, such as in certain patient groups.

TECHNICAL FIELD OF THE INVENTION

The invention describes DPP-4 inhibitors, pharmaceutical compositions orcombinations comprising a DPP-4 inhibitor as defined herein andoptionally one or more other active substances, for use in methods oftreatment or prevention as described herein, such as e.g. of one or moreconditions selected from type 1 diabetes mellitus, type 2 diabetesmellitus, impaired glucose tolerance, impaired fasting blood glucose andhyperglycemia inter alia. In a particular embodiment, the therapeuticand/or preventive methods of this invention comprise the step ofidentifying a patient being susceptible to the treatment and/orprevention, said identifying comprising testing whether the patient hasvariation(s) in one or more genes associated with metabolic diseases(e.g. whether the patient is of a TCF7L2 risk genotype as describedherein) or whether the patient is of respective wild-type genotype (e.g.whether the patient is of TCF7L2 wild genotype as described herein), andthe further step of administering such DPP-4 inhibitor, pharmaceuticalcomposition or combination to the patient determined as beingsusceptible.

Further, in one embodiment, the usability of a DPP-4 inhibitor, apharmaceutical composition, combination or medicament each as describedherein for a therapeutic and/or preventive method or use according thisinvention in a patient who has variation(s) in one or more genesassociated with metabolic diseases (such as e.g. a TCF7L2 risk genotypepatient as described herein) is contemplated.

TCF7L2 risk genotype patients according to this invention include,without being limited, patients (particularly type 2 diabetes patients)harboring genetic risk variants in the gene TCF7L2 and suffering oftenfrom the pathological influences thereof, particularly associated withthe risk T-allele of TCF7L2 rs7903146, such as patients harboring theTCF7L2 rs7903146 CT heterozygous risk genotype or patients harboring theTCF7L2 rs7903146 TT homozygous high risk genotype.

Further, in another embodiment, the usability of a DPP-4 inhibitor, apharmaceutical composition, combination or medicament each as describedherein for a therapeutic and/or preventive method or use according thisinvention in a patient who carries the TCF7L2 wild genotype,particularly the TCF7L2 rs7903146 CC wild genotype, is contemplated.

Moreover, the present invention provides a diagnostic method foridentifying a subject (particularly a type 2 diabetes patient)statistically more likely to have a favorable response (e.g. inachieving glycemic control, such as change in HbA1c) to theadministration of a therapeutically effective amount of a DPP-4inhibitor, optionally in combination with one or more other activesubstances (e.g. antidiabetics), said method comprising determiningwhether the subject is either of TCF7L2 risk genotype (particularlyTCF7L2 rs7903146 CT or TT risk genotype) or of TCF7L2 wild genotype(particularly TCF7L2 rs7903146 CC wild genotype), wherein the subjectbeing of TCF7L2 rs7903146 CC homozygous wild genotype (and, to a lesserextent, the subject being of TCF7L2 rs7903146 CT heterozygous riskgenotype) has an increased likelihood of favorable response to theadministered DPP-4 inhibitor relative to a subject of TCF7L2 rs7903146TT homozygous risk genotype.

Furthermore the invention describes a method

-   -   for preventing, slowing progression of, delaying, or treating a        metabolic disorder;    -   for improving glycemic control and/or for reducing of fasting        plasma glucose, of postprandial plasma glucose and/or of        glycosylated hemoglobin HbA1c;    -   for preventing, slowing, delaying or reversing progression from        impaired glucose tolerance, impaired fasting blood glucose,        insulin resistance and/or from metabolic syndrome to type 2        diabetes mellitus;    -   for preventing, slowing progression of, delaying or treating of        a condition or disorder selected from the group consisting of        complications of diabetes mellitus;    -   for reducing body weight and/or body fat or preventing an        increase in body weight and/or body fat or facilitating a        reduction in body weight and/or body fat;    -   for preventing or treating the degeneration of pancreatic beta        cells and/or for improving and/or restoring or protecting the        functionality of pancreatic beta cells and/or restoring the        functionality of pancreatic insulin secretion;    -   for preventing, slowing, delaying or treating diseases or        conditions attributed to an abnormal accumulation of liver or        ectopic fat; or    -   for maintaining and/or improving the insulin sensitivity and/or        for treating or preventing hyperinsulinemia and/or insulin        resistance;    -   for preventing, slowing progression of, delaying, or treating        new onset diabetes after transplantation (NODAT) and/or        post-transplant metabolic syndrome (PTMS);    -   for preventing, delaying, or reducing NODAT and/or PTMS        associated complications including micro- and macrovascular        diseases and events, graft rejection, infection, and death;    -   for treating hyperuricemia and hyperuricemia associated        conditions;

in patients in need thereof, for example in those patients (particularlytype 2 diabetes mellitus patients) who have variation(s) in one or moregenes associated with metabolic diseases (such as e.g. in a TCF7L2 riskgenotype patient as described herein) or in those patients which are ofrespective wild-type genotype (such as e.g. in a TCF7L2 wild genotype asdescribed herein), wherein said method comprises

testing the patient whether he/she has variation(s) in one or more genesassociated with metabolic diseases (e.g. whether he/she is of a TCF7L2risk genotype as described herein) or whether the patient is ofrespective wild-type genotype (e.g. whether the patient is of TCF7L2wild genotype as described herein), and

administering a DPP-4 inhibitor as defined hereinafter (preferablylinagliptin), optionally in combination with one or more other activesubstances.

In addition, the present invention describes the use of a DPP-4inhibitor for the manufacture of a medicament for use in a method asdescribed hereinbefore and hereinafter.

In addition, the present invention describes a DPP-4 inhibitor for usein a therapy of a patient (particularly human type 2 diabetes patient)as described hereinbefore and hereinafter.

In addition, the present invention describes a DPP-4 inhibitor for usein a treatment or prevention of a (particularly metabolic) disease,disorder or condition (particularly diabetes, especially type 2diabetes, and conditions related thereto, such as e.g. diabeticcomplications) as described hereinbefore and hereinafter.

The invention also describes a use of a pharmaceutical composition orcombination according to this invention for the manufacture of amedicament for use in a method as described hereinbefore andhereinafter.

The invention also relates to the DPP-4 inhibitors as defined herein foruse in a method as described hereinbefore and hereinafter, said methodcomprising administering the DPP-4 inhibitor, optionally in combinationwith one or more other active substances (e.g. which may selected fromthose mentioned herein), to the patient.

BACKGROUND OF THE INVENTION

Type 2 diabetes is an increasingly prevalent disease that due to a highfrequency of complications leads to a significant reduction of lifeexpectancy. Because of diabetes-associated microvascular complications,type 2 diabetes is currently the most frequent cause of adult-onset lossof vision, renal failure, and amputations in the industrialized world.In addition, the presence of type 2 diabetes is associated with a two tofive fold increase in cardiovascular disease risk.

After long duration of disease, most patients with type 2 diabetes willeventually fail on oral therapy and become insulin dependent with thenecessity for daily injections and multiple daily glucose measurements.

The UKPDS (United Kingdom Prospective Diabetes Study) demonstrated thatintensive treatment with metformin, sulfonylureas or insulin resulted inonly a limited improvement of glycemic control (difference in HbA1c˜0.9%). In addition, even in patients within the intensive treatment armglycemic control deteriorated significantly over time and this wasattributed to deterioration of β-cell function. Importantly, intensivetreatment was not associated with a significant reduction inmacrovascular complications, i.e. cardiovascular events. Therefore manypatients with type 2 diabetes remain inadequately treated, partlybecause of limitations in long term efficacy, tolerability and dosinginconvenience of existing antihyperglycemic therapies.

Oral and non-oral antidiabetic drugs conventionally used in therapy(such as e.g. first- or second-line, and/or mono- or (initial or add-on)combination therapy) include, without being restricted thereto,metformin, sulphonylureas, thiazolidinediones, glinides, a-glucosidaseinhibitors, GLP-1 or GLP-1 analogues, and insulin or insulin analogues.

The high incidence of therapeutic failure is a major contributor to thehigh rate of long-term hyperglycemia-associated complications or chronicdamages (including micro- and makrovascular complications such as e.g.diabetic nephrophathy, retinopathy or neuropathy, or cardiovascularcomplications) in patients with type 2 diabetes.

Genetic association studies have identified genetic variations inseveral genes which are associated with increased risk of type 2diabetes mellitus. E.g. variations in the genes TCF7L2, KCNJ11 and PPARGindependently and interactively increase the risk of progression fromimpaired fasting glucose and impaired glucose tolerance to overtdiabetes. While variation in KCNJ11 may alter insulin secretion andvariation in PPARG may alter insulin action, TCF7L2 (transcriptionfactor 7-like 2) is the major susceptibility gene identified to date fortype 2 diabetes in various ethnic groups (e.g. Europeans, Indian andJapanese people, Mexican Americans and West Africans). Polymorphisms(single nucleotid polymorphisms, so called SNPs) in TCF7L2, such as e.g.rs12255372 and, particularly, rs7903146, are strongly associated withdiabetes. The risk of developing type 2 diabetes is increased by roughly45% (Odds ratio 1.45) among carriers of one risk T-allele of TCF7L2rs7903146 (CT heterozygotes), and is at least doubled (Odds ratio of2.41) among TT homozygotes compared to CC homozygotes wild genotypes(Grant et al, Nature Genetics, Vol. 38, 2006, p 320-323). TCF7L2 riskgenotypes are associated with increased TCF7L2 expression in pancreaticbeta cells, impaired (glucose-stimulated) insulin secretion, incretineffects and enhanced rate of hepatic glucose production as well aspredisposition to and prediction of future type 2 diabetes (cf. Lyssenkoet al., The Journal of Clinical Investigation, Vol. 117, No 8, 2007, p.2155-2163). There is evidence that the TCF7L2 rs7903146 risk variantsare associated with lower incretin effect on insulin secretion, whichmay be based, at least in parts, on an impaired sensitivity of the betacells to incretins.

Thus, diabetes patients harboring TCF7L2 risk variants, particularlycarriers of the at risk T-allele of TCF7L2 rs7903146, such as patientsharboring the TCF7L2 rs7903146 CT genotype or, particularly, patientsharboring the TCF7L2 rs7903146 TT genotype, are expected to be difficultto treat in antidiabetic therapy.

Therefore, there is an unmet medical need for methods, medicaments andpharmaceutical compositions or combinations with a good efficacy withregard to glycemic control, with regard to disease-modifying propertiesand with regard to reduction of cardiovascular morbidity and mortalitywhile at the same time showing an improved safety profile.

DPP-4 inhibitors represent another novel class of agents that are beingdeveloped for the treatment or improvement in glycemic control inpatients with type 2 diabetes.

For example, DPP-4 inhibitors and their uses are disclosed in WO2002/068420, WO 2004/018467, WO 2004/018468, WO 2004/018469, WO2004/041820, WO 2004/046148, WO 2005/051950, WO 2005/082906, WO2005/063750, WO 2005/085246, WO 2006/027204, WO 2006/029769,W02007/014886; WO 2004/050658, WO 2004/111051, WO 2005/058901, WO2005/097798; WO 2006/068163, WO 2007/071738, WO 2008/017670; WO2007/128721, WO 2007/128724, WO 2007/128761, or WO 2009/121945.

AIM OF THE PRESENT INVENTION

The aim of the present invention is to provide a medication and/ormethod for preventing, slowing progression of, delaying or treating ametabolic disorder, in particular of type 2 diabetes mellitus.

A further aim of the present invention is to provide a medication and/ormethod for improving glycemic control in a patient in need thereof, inparticular in patients with type 2 diabetes mellitus, for example inthose patients who have variation(s) in one or more genes associatedwith metabolic diseases (such as e.g. a TCF7L2 risk genotype patient asdescribed herein) or in those patients who are of respective wild-typegenotype.

Another aim of the present invention is to provide a medication and/ormethod for improving glycemic control in a patient with insufficientglycemic control despite monotherapy with an antidiabetic drug, forexample metformin, or despite combination therapy with two or threeantidiabetic drugs, for example in such a patient who has variation(s)in one or more genes associated with metabolic diseases (such as e.g. aTCF7L2 risk genotype patient as described herein) or in such a patientwho is of respective wild-type genotype.

Another aim of the present invention is to provide a medication and/ormethod for preventing, slowing or delaying progression from impairedglucose tolerance (IGT), impaired fasting blood glucose (IFG), insulinresistance and/or metabolic syndrome to type 2 diabetes mellitus.

Yet another aim of the present invention is to provide a medicationand/or method for preventing, slowing progression of, delaying ortreating of a condition or disorder from the group consisting ofcomplications of diabetes mellitus.

A further aim of the present invention is to provide a medication and/ormethod for reducing the weight or preventing an increase of the weightin a patient in need thereof, for example in such a patient who hasvariation(s) in one or more genes associated with metabolic diseases(such as e.g. a TCF7L2 risk genotype patient as described herein) or insuch a patient who is of respective wild-type genotype.

Another aim of the present invention is to provide a medication with ahigh efficacy for the treatment of metabolic disorders, in particular ofdiabetes mellitus, impaired glucose tolerance (IGT), impaired fastingblood glucose (IFG), and/or hyperglycemia, which has good to very goodpharmacological and/or pharmacokinetic and/or physicochemicalproperties.

Further aims of the present invention become apparent to the one skilledin the art by description hereinbefore and in the following and by theexamples.

SUMMARY OF THE INVENTION

Within the scope of the present invention it has now been found that aDPP-4 inhibitor, preferably linagliptin, as well as a pharmaceuticalcomposition or combination comprising the DPP-4 inhibitor and optionallyone or more other active substances (e.g. antidiabetics), istherapeutically effective for improving glycemic control and treatingtype 2 diabetes mellitus in TCF7L2 rs7903146 CT or TT risk genotypepatients and in TCF7L2 rs7903146 CC wild genotype patients.

In particular, it has been found that all investigated TCF7L2 genotypepatients (patients with TCF7L2 rs7903146 CT or TT risk genotype or withTCF7L2 rs7903146 CC wild genotype) have a clinically meaningful responseto the administered DPP-4 inhibitor, preferably linagliptin.

Thus, within the scope of the present invention, certain subgroups ofdiabetes patients amenable to antidiabetic therapy according to thisinvention (comprising using preferably linagliptin, optionally incombination with one or more other active substances such as e.g. otherantidiabetics as described herein), include for example, without beinglimited to, those patients harboring TCF7L2 rs7903146 CC or CT or TTgenotype, respectively.

Within the scope of the present invention it has further been found thatDPP-4 inhibitors as defined herein as well as pharmaceuticalcompositions or combinations comprising a DPP-4 inhibitor as definedherein and optionally one or more other active substances can be used ina method of preventing, slowing progression of, delaying (e.g. delayingthe onset of) or treating a metabolic disorder (particularly diabetes,especially type 2 diabetes mellitus and conditions related thereto, e.g.diabetic complications), in particular a method for improving glycemiccontrol in a patient, such as in a patient who has variation(s) in oneor more genes associated with metabolic diseases (such as e.g. in TCF7L2risk genotype patients as described herein).

Within the scope of the present invention it has further been found thatDPP-4 inhibitors as defined herein as well as pharmaceuticalcompositions or combinations comprising a DPP-4 inhibitor as definedherein and optionally one or more other active substances can be used ina method of preventing, slowing progression of, delaying (e.g. delayingthe onset of) or treating a metabolic disorder (particularly diabetes,especially type 2 diabetes mellitus and conditions related thereto), inparticular a method for improving glycemic control in a patient, such asin a patient who is of TCF7L2 wild genotype, particularly of TCF7L2rs7903146 CC wild genotype.

In an embodiment the method comprises the step of of identifying apatient being susceptible to the method being used, e.g. comprisingtesting whether the patient has variation(s) in one or more genesassociated with metabolic diseases (e.g. whether the patient is of aTCF7L2 risk genotype as described herein) or whether the patient is ofTCF7L2 wild genotype as described herein, and the step of administeringsuch a DPP-4 inhibitor, pharmaceutical composition or combination to thepatient determined as being susceptible.

This opens up new therapeutic possibilities in the treatment andprevention of type 2 diabetes mellitus, overweight, obesity,complications of diabetes mellitus and of neighboring disease states,including such patients who have variation(s) in one or more genesassociated with metabolic diseases (such as e.g. in TCF7L2 risk genotypepatients as described herein) and such patients who are of respectivewild-type genotype (such as e.g. TCF7L2 wild genotype patients asdescribed herein).

Moreover, the present invention provides a method for determining of aprobability of the likelihood of a favorable response (e.g. in providingglycemic control) or the magnitude of a favorable change in HbA1c of anindividual resulting from treating the individual with a DPP-4inhibitor, preferably linagliptin, or the DPP-4 inhibitor in combinationwith one or more other active substances (e.g. antidiabetics), saidmethod comprising determining whether the subject is either of TCF7L2risk genotype (particularly TCF7L2 rs7903146 TT risk genotype) or ofTCF7L2 wild genotype (particularly TCF7L2 rs7903146 CC wild genotype),wherein the probability of likelihood of a favorable response or thesignificantly high magnitude of a favorable change in HbA1c response toadministration of the DPP-4 inhibitor, preferably linagliptin, or theDPP-4 inhibitor in combination with one or more other active substances(e.g. antidiabetics) is

greater in an individual being of TCF7L2 rs7903146 CC homozygous wildgenotype, and lower in an individual of TCF7L2 rs7903146 TT homozygousrisk genotype (e.g. but still clinically significant or meaningful).

Therefore, in a one aspect there is provided a pharmaceuticalcomposition or combination comprising

(a) a DPP-4 inhibitor, and, optionally,

(b) a second antidiabetic agent selected from the group G3 consisting ofbiguanides (particularly metformin), thiazolidindiones, sulfonylureas,glinides, inhibitors of alpha-glucosidase, GLP-1 or GLP-1 analogues andinsulin or insulin analogues, and, optionally,

(c) a third antidiabetic agent being different from (b) selected fromthe group G3 consisting of biguanides (particularly metformin),thiazolidindiones, sulfonylureas, glinides, inhibitors ofalpha-glucosidase, GLP-1 or GLP-1 analogues and insulin or insulinanalogues,

or a pharmaceutically acceptable salt thereof.

In a subaspect there is provided a pharmaceutical composition orcombination comprising

(a) a DPP-4 inhibitor, and, optionally,

(b) a second antidiabetic agent selected from the group G3 consisting ofbiguanides (particularly metformin), thiazolidindiones, sulfonylureas,glinides, inhibitors of alpha-glucosidase, GLP-1 or GLP-1 analogues andinsulin or insulin analogues, and, optionally,

(c) a third antidiabetic agent being different from (b) selected fromthe group consisting of metformin, a sulfonylurea, pioglitazone,rosiglitazone, repaglinide, nateglinide, acarbose, voglibose, miglitol,GLP-1 or a GLP-1 analogue and insulin or an insulin analogue,

or a pharmaceutically acceptable salt thereof.

In another subaspect there is provided a pharmaceutical composition orcombination comprising

(a) a DPP-4 inhibitor, and, optionally,

(b) a second antidiabetic agent selected from the group consisting ofmetformin, a sulfonylurea, pioglitazone, rosiglitazone, repaglinide,nateglinide, acarbose, voglibose, miglitol, GLP-1 or a GLP-1 analogueand insulin or an insulin analogue, and, optionally,

(c) a third antidiabetic agent being different from (b) selected fromthe group G3 consisting of biguanides (particularly metformin),thiazolidindiones, sulfonylureas, glinides, inhibitors ofalpha-glucosidase, GLP-1 or GLP-1 analogues and insulin or insulinanalogues,

or a pharmaceutically acceptable salt thereof.

In a further subaspect there is provided a pharmaceutical composition orcombination comprising

(a) a DPP-4 inhibitor, and, optionally,

(b) a second antidiabetic agent selected from the group consisting ofmetformin, a sulfonylurea and pioglitazone, and, optionally,

(c) a third antidiabetic agent being different from (b) selected fromthe group consisting of metformin, a sulfonylurea, pioglitazone,rosiglitazone, repaglinide, nateglinide, acarbose, voglibose, miglitol,GLP-1 or GLP-1 analogue and insulin or insulin analogue,

or a pharmaceutically acceptable salt thereof.

In a further subaspect there is provided a pharmaceutical composition orcombination comprising

(a) a DPP-4 inhibitor, and, optionally,

(b) a second antidiabetic agent selected from the group consisting ofmetformin, a sulfonylurea, pioglitazone, rosiglitazone, repaglinide,nateglinide, acarbose, voglibose, miglitol, GLP-1 or GLP-1 analogue andinsulin or insulin analogue, and, optionally,

(c) a third antidiabetic agent being different from (b) selected fromthe group consisting of metformin, a sulfonylurea and pioglitazone,

or a pharmaceutically acceptable salt thereof.

In a yet further subaspect there is provided a pharmaceuticalcomposition or combination comprising

(a) a DPP-4 inhibitor, and, optionally,

(b) a second antidiabetic agent selected from the group consisting ofmetformin and pioglitazone, and, optionally,

(c) a third antidiabetic agent being different from (b) selected fromthe group consisting of metformin, a sulfonylurea and pioglitazone,

or a pharmaceutically acceptable salt thereof.

In a yet further subaspect there is provided a pharmaceuticalcomposition or combination comprising

(a) a DPP-4 inhibitor, and, optionally,

(b) a second antidiabetic agent selected from the group consisting ofmetformin, a sulfonylurea and pioglitazone, and, optionally,

(c) a third antidiabetic agent being different from (b) selected fromthe group consisting of metformin and pioglitazone,

or a pharmaceutically acceptable salt thereof.

When—besides the second anidiabetic agent—a third antidiabetic agent ischosen, said third antidiabetic agent is preferably chosen from anotherclass than the second antidiabetic agent. Thus, it is to be understoodthat the second and the third antidiabetic agent are different, andpreferably they are from different classes (e.g. when the secondantidiabetic agent is chosen from the biguanide class, the thirdantidiabetic agent is preferably chosen from another class). Classes ofantidiabetic agents are mentioned above, e.g. biguanide class,thiazolidindione class, sulfonylurea class, glinide class,alpha-glucosidase inhibitor class, GLP-1 analogue class, insulin class,etc.

A particular embodiment of this invention refers to monotherapy with aDPP-4 inhibitor as defined herein and/or to pharmaceutical compositionscomprising a DPP-4 inhibitor as sole active ingredient.

Within combinations and/or combination therapy of this invention, aparticular embodiment refers to dual combinations and/or dual therapy;another embodiment refers to triple combinations and/or triple therapy.

According to another aspect there is provided a method for preventing,slowing the progression of, delaying or treating a metabolic disorderselected from the group consisting of type 1 diabetes mellitus, type 2diabetes mellitus, impaired glucose tolerance (IGT), impaired fastingblood glucose (IFG), hyperglycemia, postprandial hyperglycemia,overweight, obesity and metabolic syndrome in a patient in need thereofcharacterized in that a DPP-4 inhibitor and, optionally, a second and,optionally, a third antidiabetic agent as defined hereinbefore andhereinafter are administered, for example in combination, to thepatient.

According to another aspect there is provided a method for preventing,slowing the progression of, delaying or treating a metabolic disorderselected from the group consisting of insulin resistance,hyperlipidemia, hypercholesterolemia, dyslipidemia, hypertension,chronic systemic inflammation, retinopathy, neuropathy, nephropathy,atherosclerosis, endothelial dysfunction, non-alcoholic fatty liverdisease (NAFLD) and osteoporosis in a patient in need thereofcharacterized in that a DPP-4 inhibitor and, optionally, a second and,optionally, a third antidiabetic agent as defined hereinbefore andhereinafter are administered, for example in combination, to thepatient.

According to another aspect there is provided a method for improvingglycemic control and/or for reducing of fasting plasma glucose, ofpostprandial plasma glucose and/or of glycosylated hemoglobin HbA1c in apatient in need thereof characterized in that a DPP-4 inhibitor and,optionally, a second and, optionally, a third antidiabetic agent asdefined hereinbefore and hereinafter are administered, for example incombination, to the patient.

The pharmaceutical composition of this invention may also have valuabledisease-modifying properties with respect to diseases or conditionsrelated to impaired glucose tolerance (IGT), impaired fasting bloodglucose (IFG), insulin resistance and/or metabolic syndrome.

According to another aspect there is provided a method for preventing,slowing, delaying or reversing progression from impaired glucosetolerance (IGT), impaired fasting blood glucose (IFG), insulinresistance and/or from metabolic syndrome to type 2 diabetes mellitus ina patient in need thereof characterized in that a DPP-4 inhibitor and,optionally, a second and, optionally, a third antidiabetic agent asdefined hereinbefore and hereinafter are administered, for example incombination, to the patient.

As by the use of a pharmaceutical composition or combination of thisinvention, an improvement of the glycemic control in patients in needthereof is obtainable, also those conditions and/or diseases related toor caused by an increased blood glucose level may be treated.

According to another aspect there is provided a method for preventing,slowing the progression of, delaying or treating of a condition ordisorder selected from the group consisting of complications of diabetesmellitus such as cataracts and micro- and macrovascular diseases, suchas nephropathy, retinopathy, neuropathy, learning and memory impairment,neurodegenerative or cognitive disorders, cardio- or cerebrovasculardiseases, arteriosclerosis, hypertension, endothelial dysfunction,myocardial infarction, accute coronary syndrome, unstable anginapectoris, stable angina pectoris, cardiomyopathy, heart failure, heartrhythm disorders, vascular restenosis, peripheral arterial occlusivedisease, stroke, tissue ischaemia or diabetic foot or ulcus, in apatient in need thereof characterized in that a DPP-4 inhibitor and,optionally, a second and, optionally, a third antidiabetic agent asdefined hereinbefore and hereinafter are administered, for example incombination, to the patient. In particular one or more aspects ofdiabetic nephropathy such as hyperperfusion, proteinuria and albuminuria(including micro- or macroalbuminuria) may be treated, their progressionslowed or their onset delayed or prevented. The term “tissue ischaemia”particularly comprises diabetic macroangiopathy, diabeticmicroangiopathy, impaired wound healing and diabetic ulcer. The terms“micro- and macrovascular diseases” and “micro- and macrovascularcomplications” are used interchangeably in this application.

In an embodiment, by the administration of a pharmaceutical compositionor combination of this invention no gain in weight or even a reductionin body weight is the result.

According to another aspect there is provided a method for reducing bodyweight and/or body fat or preventing an increase in body weight and/orbody fat or facilitating a reduction in body weight and/or body fat in apatient in need thereof characterized in that a DPP-4 inhibitor and,optionally, a second and, optionally, a third antidiabetic agent asdefined hereinbefore and hereinafter are administered, for example incombination, to the patient.

In an embodiment, by an administration of a pharmaceutical compositionor combination according to this invention a beta-cell degeneration anda decline of beta-cell functionality such as for example apoptosis ornecrosis of pancreatic beta cells can be delayed or prevented.Furthermore, the functionality of pancreatic cells can be improved orrestored, and the number and size of pancreatic beta cells increased. Itmay be shown that the differentiation status and hyperplasia ofpancreatic beta-cells disturbed by hyperglycemia can be normalized bytreatment with a pharmaceutical composition or combination of thisinvention.

According to another aspect there is provided a method for preventing,slowing, delaying or treating the degeneration of pancreatic beta cellsand/or the decline of the functionality of pancreatic beta cells and/orfor improving and/or restoring the functionality of pancreatic betacells and/or restoring the functionality of pancreatic insulin secretionin a patient in need thereof characterized in that a DPP-4 inhibitorand, optionally, a second and, optionally, a third antidiabetic agent asdefined hereinbefore and hereinafter are administered, for example incombination, to the patient.

In an embodiment, by the administration of a pharmaceutical compositionor combination of the present invention, an abnormal accumulation of(ectopic) fat, in particular in the liver, may be reduced or inhibited.

According to another aspect there is provided a method for preventing,slowing, delaying or treating diseases or conditions attributed to anabnormal accumulation of liver or ectopic fat in a patient in needthereof characterized in that a DPP-4 inhibitor and, optionally, asecond and, optionally, a third antidiabetic agent as definedhereinbefore and hereinafter are administered, for example incombination, to the patient. Diseases or conditions which are attributedto an abnormal accumulation of liver or ectopic fat are particularlyselected from the group consisting of general fatty liver, non-alcoholicfatty liver (NAFL), non-alcoholic steatohepatitis (NASH),hyperalimentation-induced fatty liver, diabetic fatty liver,alcoholic-induced fatty liver or toxic fatty liver, particularlynon-alcoholic fatty liver disease (NAFLD), including hepatic steatosis,non-alcoholic steatohepatitis (NASH) and/or liver fibrosis.

According to a further aspect of the present invention, there isprovided a method for preventing, slowing the progression, delaying,attenuating, treating or reversing hepatic steatosis, (hepatic)inflammation and/or an abnormal accumulation of liver fat in a patientin need thereof characterized in that a DPP-4 inhibitor and, optionally,a second and, optionally, a third antidiabetic agent as definedhereinbefore and hereinafter are administered, for example incombination, to the patient.

According to another aspect there is provided a method for maintainingand/or improving the insulin sensitivity and/or for treating orpreventing hyperinsulinemia and/or insulin resistance in a patient inneed thereof characterized in that a DPP-4 inhibitor and, optionally, asecond and, optionally, a third antidiabetic agent as definedhereinbefore and hereinafter are administered, for example incombination, to the patient.

According to another aspect of the invention, there is provided a methodfor preventing, slowing progression of, delaying, or treating new onsetdiabetes after transplantation (NODAT) and/or post-transplant metabolicsyndrome (PTMS) in a patient in need thereof characterized in that aDPP-4 inhibitor and, optionally, a second and, optionally, a thirdantidiabetic agent as defined hereinbefore and hereinafter areadministered, for example in combination, to the patient.

According to a further aspect of the invention, there is provided amethod for preventing, delaying, or reducing NODAT and/or PTMSassociated complications including micro- and macrovascular diseases andevents, graft rejection, infection, and death in a patient in needthereof characterized in that a DPP-4 inhibitor and, optionally, asecond and, optionally, a third antidiabetic agent as definedhereinbefore and hereinafter are administered, for example incombination, to the patient.

According to another aspect of the invention, there is provided a methodfor treating hyperuricemia and hyperuricemia-associated conditions, suchas for example gout, hypertension and renal failure, in a patient inneed thereof characterized in that a DPP-4 inhibitor and, optionally, asecond and, optionally, a third antidiabetic agent as definedhereinbefore and hereinafter are administered, for example incombination, to the patient.

According to another aspect there is provided the use of a DPP-4inhibitor for the manufacture of a medicament for use in a method of

-   -   preventing, slowing the progression of, delaying or treating a        metabolic disorder selected from the group consisting of type 1        diabetes mellitus, type 2 diabetes mellitus, impaired glucose        tolerance (IGT), impaired fasting blood glucose (IFG),        hyperglycemia, postprandial hyperglycemia, overweight, obesity        and metabolic syndrome; or    -   improving glycemic control and/or for reducing of fasting plasma        glucose, of postprandial plasma glucose and/or of glycosylated        hemoglobin HbA1c; or    -   preventing, slowing, delaying or reversing progression from        impaired glucose tolerance (IGT), impaired fasting blood glucose        (IFG), insulin resistance and/or from metabolic syndrome to type        2 diabetes mellitus; or    -   preventing, slowing the progression of, delaying or treating of        a condition or disorder selected from the group consisting of        complications of diabetes mellitus such as cataracts and micro-        and macrovascular diseases, such as nephropathy, retinopathy,        neuropathy, tissue ischaemia, arteriosclerosis, myocardial        infarction, stroke and peripheral arterial occlusive disease; or    -   reducing body weight and/or body fat or preventing an increase        in body weight and/or body fat or facilitating a reduction in        body weight and/or body fat; or    -   preventing, slowing, delaying or treating the degeneration of        pancreatic beta cells and/or the decline of the functionality of        pancreatic beta cells and/or for improving and/or restoring or        protecting the functionality of pancreatic beta cells and/or        restoring the functionality of pancreatic insulin secretion; or    -   preventing, slowing, delaying or treating diseases or conditions        attributed to an abnormal accumulation of liver or ectopic fat;        or    -   maintaining and/or improving the insulin sensitivity and/or for        treating or preventing hyperinsulinemia and/or insulin        resistance; or    -   preventing, slowing progression of, delaying, or treating new        onset diabetes after transplantation (NODAT) and/or        post-transplant metabolic syndrome (PTMS); or    -   preventing, delaying, or reducing NODAT and/or PTMS associated        complications including micro- and macrovascular diseases and        events, graft rejection, infection, and death; or    -   treating hyperuricemia and hyperuricemia associated conditions;

in a patient in need thereof, comprising administering the DPP-4inhibitor alone or, optionally, in combination with a second and,optionally, with a third antidiabetic agent as defined hereinbefore andhereinafter to the patient.

According to another aspect there is provided the use of a secondantidiabetic agent as defined hereinbefore and hereinafter for themanufacture of a medicament for use in a method of

-   -   preventing, slowing the progression of, delaying or treating a        metabolic disorder selected from the group consisting of type 1        diabetes mellitus, type 2 diabetes mellitus, impaired glucose        tolerance (IGT), impaired fasting blood glucose (IFG),        hyperglycemia, postprandial hyperglycemia, overweight, obesity        and metabolic syndrome; or    -   improving glycemic control and/or for reducing of fasting plasma        glucose, of postprandial plasma glucose and/or of glycosylated        hemoglobin HbA1c; or    -   preventing, slowing, delaying or reversing progression from        impaired glucose tolerance (IGT), impaired fasting blood glucose        (IFG), insulin resistance and/or from metabolic syndrome to type        2 diabetes mellitus; or    -   preventing, slowing the progression of, delaying or treating of        a condition or disorder selected from the group consisting of        complications of diabetes mellitus such as cataracts and micro-        and macrovascular diseases, such as nephropathy, retinopathy,        neuropathy, tissue ischaemia, arteriosclerosis, myocardial        infarction, stroke and peripheral arterial occlusive disease; or    -   reducing body weight and/or body fat or preventing an increase        in body weight and/or body fat or facilitating a reduction in        body weight and/or body fat; or    -   preventing, slowing, delaying or treating the degeneration of        pancreatic beta cells and/or the decline of the functionality of        pancreatic beta cells and/or for improving and/or restoring the        functionality of pancreatic beta cells and/or restoring the        functionality of pancreatic insulin secretion; or    -   preventing, slowing, delaying or treating diseases or conditions        attributed to an abnormal accumulation of liver or ectopic fat;        or    -   maintaining and/or improving the insulin sensitivity and/or for        treating or preventing hyperinsulinemia and/or insulin        resistance;

in a patient in need thereof, comprising administering the secondantidiabetic agent in combination with a DPP-4 inhibitor and,optionally, with a third antidiabetic agent as defined hereinbefore andhereinafter to the patient.

According to another aspect there is provided the use of apharmaceutical composition according to the present invention for themanufacture of a medicament for a therapeutic and preventive method asdescribed hereinbefore and hereinafter.

Patients of a TCF7L2 risk genotype (also referred to herein as TCF7L2risk genotype patients) within the meaning of this invention refer tothose patients who have one or more single nucleotide polymorphisms(SNPs) in the gene coding for TCF7L2, especially a SNP selected fromrs7903146, rs12255372 and rs10885406, especially rs7903146; in moreparticular, those patients who carry at least one T allele of SNPrs7903146 of TCF7L2, i.e. the CT genotype or TT genotype; especiallythose who carry two T alleles of SNP rs7903146 of TCF7L2, i.e. the TTgenotype, are at high-risk and are expected to be difficult to treat(e.g. to achieve adequate glycemic control).

The present invention provides a DPP-4 inhibitor (preferablylinagliptin), pharmaceutical composition, combination or medicamentaccording to the present invention for use in a therapeutic and/orpreventive method as described hereinbefore and hereinafter (e.g.treating type 2 diabetes) in one or more of the following patientgroups:

-   -   TCF7L2 high risk genotype patients carrying two T alleles of SNP        rs7903146 of TCF7L2, i.e. TT genotype (where clinically        meaningful response e.g. in glycemic control is provided),    -   TCF7L2 risk genotype patients carrying one T allele of SNP        rs7903146 of TCF7L2, i.e. CT genotype (where clinically        favorable response e.g. in glycemic control is provided),    -   TCF7L2 wild genotype patients carrying two CC alleles of SNP        rs7903146 of TCF7L2, i.e. CC genotype (where clinically more        favorable response e.g. in glycemic control is provided).

Within a particular aspect of the invention, the invention relates to aDPP-4 inhibitor, a pharmaceutical composition or combination of thepresent invention for a therapeutic and/or preventive method or use asdescribed hereinbefore and hereinafter (e.g. treating type 2 diabetes),said method or use comprising

-   -   (i) identifying a patient being susceptible to said therapeutic        and/or preventive method or use comprising testing whether the        patient is of any TCF7L2 risk genotype, particularly whether the        patient has one or more single nucleotide polymorphisms (SNPs)        in the gene coding for TCF7L2, especially a SNP selected from        rs7903146, rs12255372 and rs10885406, for example whether the        patient carries at least one T allele of SNP rs7903146 of        TCF7L2, e.g. whether the patient is of CT genotype (i.e. whether        the patient carries one T allele of SNP rs7903146 of TCF7L2) or,        particularly, whether the patient is of TT genotype (i.e.        whether the patient carries two T alleles of SNP rs7903146 of        TCF7L2), or testing whether the patient is of TCF7L2 wild        genotype, particularly whether the patient carries two C alleles        of SNP rs7903146 of TCF7L2 (i.e. whether the patient is of CC        wild genotype), and    -   (ii) administering an effective amount of the DPP-4 inhibitor,        pharmaceutical composition or combination to the patient        identified in step (i).

Within another particular aspect of the invention, the invention relatesto a DPP-4 inhibitor, a pharmaceutical composition, combination ormedicament of the present invention for a therapeutic and/or preventivemethod or use as described hereinbefore and hereinafter (e.g. treatingtype 2 diabetes) in TCF7L2 risk genotype patients, e.g. in thosepatients who have one or more single nucleotide polymorphisms (SNPs) inthe gene coding for TCF7L2, especially a SNP selected from rs7903146,rs12255372 and rs10885406, especially rs7903146; in more particular, inthose patients who carry at least one T allele of SNP rs7903146 ofTCF7L2, i.e. the CT genotype or TT genotype.

Within another particular aspect of the invention, the invention relatesto a DPP-4 inhibitor, a pharmaceutical composition, combination ormedicament of the present invention for a therapeutic and/or preventivemethod or use as described hereinbefore and hereinafter (e.g. treatingtype 2 diabetes) in TCF7L2 wild genotype patients, e.g. in thosepatients who carry two C alleles of SNP rs7903146 of TCF7L2, i.e. the CCgenotype.

In this context, a particular sub-population of the patients describedhereinbefore and hereinafter (e.g. of the patients in need of atherapeutic or preventive method as described herein), refers to thosepatients who have one or more single nucleotide polymorphisms (SNPs) inthe gene coding for TCF7L2, especially at least one SNP selected fromrs7903146, rs12255372 and rs10885406, especially rs7903146, in moreparticular, those patients who carry at least one T allele of SNPrs7903146 of TCF7L2, i.e. the CT genotype or TT genotype.

In more particular, those patients who carry at least one T allele ofSNP rs7903146 of TCF7L2, i.e. the CT genotype or TT genotype, especiallywho carry two T alleles of SNP rs7903146 of TCF7L2, i.e. the TTgenotype, are strongly susceptible to increased TCF7L2 expression inpancreatic beta cells, impaired insulin secretion, incretine effects,enhanced rate of hepatic glucose production and/or diabetes. The Tallele of rs7903146 TCF7L2 is associated with impaired insulinotropicaction of incretin hormones, reduced 24 h profiles of plasma insulin andglucagon, and increased hepatic glucose production.

Another particular sub-population of the patients described hereinbeforeand hereinafter (e.g. of the patients in need of a therapeutic orpreventive method as described herein), refers to those patients who areof TCF7L2 wild genotype, particularly those who are of the TCF7L2rs7903146 CC wild genotype.

According to one embodiment of this aspect of the invention, there isprovided a DPP-4 inhibitor, a pharmaceutical composition, combination ormedicament according to the present invention for a therapeutic and/orpreventive method or use as described hereinbefore and hereinafter(particularly for treating and/or preventing type 2 diabetes and/orobesity), in patients with reduced (glucose-stimulated) insulinsecretion, increased hepatic gluconeogenesis and/or reducedinsulinotropic effect or action of incretin hormones (e.g. GLP-1 and/orGIP), e.g. impaired incretin sensitivity, associated with a TCF7L2 riskgenotype, particularly with such a TCF7L2 risk genotype as mentionedabove.

According to another embodiment of this aspect of the invention, thereis provided a method of determining patient's treatment response to aDPP-4 inhibitor, a pharmaceutical composition, combination or medicamentaccording to the present invention, said method comprising the step ofdetermining whether the patient is of TCF7L2 risk genotype as describedherein, e.g. testing whether the patient belongs to the particularsubpopulation of TCF7L2 risk genotype carriers, or determining whetherthe patient is of TCF7L2 wild genotype, e.g. testing whether the patientcarries the wild-type CC allele at rs7903146 in TCF7L2.

According to another embodiment of this aspect of the invention, thereis provided a DPP-4 inhibitor, a pharmaceutical composition, combinationor medicament according to the present invention for use in atherapeutic and/or preventive method as described hereinbefore andhereinafter (particularly for treating and/or preventing type 2 diabetesand/or obesity) in a patient in need thereof, said method comprisingtesting whether the patient is of any TCF7L2 risk genotype as describedherein.

According to another embodiment of this aspect of the invention, thereis provided a DPP-4 inhibitor, a pharmaceutical composition, combinationor medicament according to the present invention for use in atherapeutic and/or preventive method as described hereinbefore andhereinafter (particularly for treating and/or preventing type 2 diabetesand/or obesity) in a patient in need thereof, said method comprisingtesting whether the patient is of TCF7L2 wild genotype as describedherein.

According to another aspect of the invention, the testing for TCF7L2risk genotypes may be used for patient stratification, e.g. to enrichpatient population in clinical trials to test the efficacy of the DPP-4inhibitor.

According to another aspect of the invention, the method of determiningthe treatment susceptibility of an individual (e.g. comprising thetesting for TCF7L2 risk or wild genotypes as described herein) may beused for determination whether the patient may respond to a lower levelor may require a higher level of administered DPP-4 inhibitor,optionally in combination with one or more other active substances.

According to another aspect of the invention, determining the treatmentsusceptibility of an individual comprising the testing for TCF7L2 riskor wild genotypes as described herein may be used for determinationwhether the patient may be treated in monotherapy or in combinationtherapy with one or more additional antidiabetics according to thisinvention, e.g. to provide adequate glycemic control. For example, thosepatients with decreased likelihood of favorable response may requirecombination treatment, e.g. to achieve adequate glycemic control.

BRIEF DESCRIPTION OF THE SEVERAL VIEWS OF THE DRAWINGS

FIG. 1 shows mean values and 95% confidence intervals for baseline HbA1cvalues for the whole patient population of the studies (full analysisset, FAS), for the subpopulation for which genetic analyses areperformed (full analysis set for pharmacogenetic analyses, FASG), aswell as for the subgroups defined by genotype (CC, CT, TT) of thissubpopulation. The numbers of patients for placebo control andlinagliptin treatment are given in braces.

FIG. 2 shows a statistical association between TCF7L2 SNP rs7903146genotypes with a likelihood of a favorable response in CC/CT genotypecarriers to the administration of a therapeutically-effective amount oflinagliptin or linagliptin in combination with other oral antidiabetictherapy.

DETAILED DESCRIPTION OF THE INVENTION

Definitions

The term “active ingredient” of a pharmaceutical composition orcombination of the present invention means the DPP-4 inhibitor and/or,if present, the second antidiabetic agent and/or, if present, the thirdantidiabetic agent of the present invention.

The term “body mass index” or “BMI” of a human patient is defined as theweight in kilograms divided by the square of the height in meters, suchthat BMI has units of kg/m².

The term “overweight” is defined as the condition wherein the individualhas a BMI greater than or 25 kg/m² and less than 30 kg/m². The terms“overweight” and “pre-obese” are used interchangeably.

The term “obesity” is defined as the condition wherein the individualhas a BMI equal to or greater than 30 kg/m². According to a WHOdefinition the term obesity may be categorized as follows: the term“class I obesity” is the condition wherein the BMI is equal to orgreater than 30 kg/m² but lower than 35 kg/m²; the term “class IIobesity” is the condition wherein the BMI is equal to or greater than 35kg/m² but lower than 40 kg/m²; the term “class III obesity” is thecondition wherein the BMI is equal to or greater than 40 kg/m².

The term “visceral obesity” is defined as the condition wherein awaist-to-hip ratio of greater than or equal to 1.0 in men and 0.8 inwomen is measured. It defines the risk for insulin resistance and thedevelopment of pre-diabetes.

The term “abdominal obesity” is usually defined as the condition whereinthe waist circumference is >40 inches or 102 cm in men, and is >35inches or 94 cm in women. With regard to a Japanese ethnicity orJapanese patients abdominal obesity may be defined as waistcircumference ≥85 cm in men and ≥90 cm in women (see e.g. investigatingcommittee for the diagnosis of metabolic syndrome in Japan).

The term “euglycemia” is defined as the condition in which a subject hasa fasting blood glucose concentration within the normal range, greaterthan 70 mg/dL (3.89 mmol/L) and less than 110 mg/dL (6.11 mmol/L) or 100mg mg/dL (5.6 mmol/L). The word “fasting” has the usual meaning as amedical term.

The term “hyperglycemia” is defined as the condition in which a subjecthas a fasting blood glucose concentration above the normal range,greater than 110 mg/dL (6.11 mmol/L) or 100 mg mg/dL (5.6 mmol/L). Theword “fasting” has the usual meaning as a medical term.

The term “hypoglycemia” is defined as the condition in which a subjecthas a blood glucose concentration below the normal range of 60 to 115mg/dL (3.3 to 6.3 mmol/L), in particular below 70 mg/dL (3.89 mmol/L).

The term “postprandial hyperglycemia” is defined as the condition inwhich a subject has a 2 hour postprandial blood glucose or serum glucoseconcentration greater than 200 mg/dL (11.11 mmol/L).

The term “impaired fasting blood glucose” or “IFG” is defined as thecondition in which a subject has a fasting blood glucose concentrationor fasting serum glucose concentration in a range from 100 to 125 mg/dl(i.e. from 5.6 to 6.9 mmol/l), in particular greater than 110 mg/dL andless than 126 mg/dl (7.00 mmol/L). A subject with “normal fastingglucose” has a fasting glucose concentration smaller than 100 mg/dl,i.e. smaller than 5.6 mmol/l.

The term “impaired glucose tolerance” or “IGT” is defined as thecondition in which a subject has a 2 hour postprandial blood glucose orserum glucose concentration greater than 140 mg/dl (7.78 mmol/L) andless than 200 mg/dL (11.11 mmol/L). The abnormal glucose tolerance, i.e.the 2 hour postprandial blood glucose or serum glucose concentration canbe measured as the blood sugar level in mg of glucose per dL of plasma 2hours after taking 75 g of glucose after a fast. A subject with “normalglucose tolerance” has a 2 hour postprandial blood glucose or serumglucose concentration smaller than 140 mg/dl (7.78 mmol/L).

The term “hyperinsulinemia” is defined as the condition in which asubject with insulin resistance, with or without euglycemia, has fastingor postprandial serum or plasma insulin concentration elevated abovethat of normal, lean individuals without insulin resistance, having awaist-to-hip ratio <1.0 (for men) or <0.8 (for women).

The terms “insulin-sensitizing”, “insulin resistance-improving” or“insulin resistance-lowering” are synonymous and used interchangeably.

The term “insulin resistance” is defined as a state in which circulatinginsulin levels in excess of the normal response to a glucose load arerequired to maintain the euglycemic state (Ford E S, et al. JAMA. (2002)287:356-9). A method of determining insulin resistance is theeuglycaemic-hyperinsulinaemic clamp test. The ratio of insulin toglucose is determined within the scope of a combined insulin-glucoseinfusion technique. There is found to be insulin resistance if theglucose absorption is below the 25th percentile of the backgroundpopulation investigated (WHO definition). Rather less laborious than theclamp test are so called minimal models in which, during an intravenousglucose tolerance test, the insulin and glucose concentrations in theblood are measured at fixed time intervals and from these the insulinresistance is calculated. With this method, it is not possible todistinguish between hepatic and peripheral insulin resistance.

Furthermore, insulin resistance, the response of a patient with insulinresistance to therapy, insulin sensitivity and hyperinsulinemia may bequantified by assessing the “homeostasis model assessment to insulinresistance (HOMA-IR)” score, a reliable indicator of insulin resistance(Katsuki A, et al. Diabetes Care 2001; 24: 362-5). Further reference ismade to methods for the determination of the HOMA-index for insulinsensitivity (Matthews et al., Diabetologia 1985, 28: 412-19), of theratio of intact proinsulin to insulin (Forst et al., Diabetes 2003,52(Suppl. 1): A459) and to an euglycemic clamp study. In addition,plasma adiponectin levels can be monitored as a potential surrogate ofinsulin sensitivity. The estimate of insulin resistance by thehomeostasis assessment model (HOMA)-IR score is calculated with theformula (Galvin P, et al. Diabet Med 1992;9:921-8):

HOMA-IR=[fasting serum insulin (μU/mL)]×[fasting plasmaglucose(mmol/L)/22.5]

As a rule, other parameters are used in everyday clinical practice toassess insulin resistance. Preferably, the patient's triglycerideconcentration is used, for example, as increased triglyceride levelscorrelate significantly with the presence of insulin resistance.

Patients with a predisposition for the development of IGT or IFG or type2 diabetes are those having euglycemia with hyperinsulinemia and are bydefinition, insulin resistant. A typical patient with insulin resistanceis usually overweight or obese. If insulin resistance can be detected,this is a particularly strong indication of the presence ofpre-diabetes. Thus, it may be that in order to maintain glucosehomoeostasis a person needs 2-3 times as much insulin as a healthyperson, without this resulting in any clinical symptoms.

The methods to investigate the function of pancreatic beta-cells aresimilar to the above methods with regard to insulin sensitivity,hyperinsulinemia or insulin resistance: An improvement of beta-cellfunction can be measured for example by determining a HOMA-index forbeta-cell function (Matthews et al., Diabetologia 1985, 28: 412-19), theratio of intact proinsulin to insulin (Forst et al., Diabetes 2003,52(Suppl. 1): A459), the insulin/C-peptide secretion after an oralglucose tolerance test or a meal tolerance test, or by employing ahyperglycemic clamp study and/or minimal modeling after a frequentlysampled intravenous glucose tolerance test (Stumvoll et al., Eur J ClinInvest 2001, 31: 380-81).

The term “pre-diabetes” is the condition wherein an individual ispre-disposed to the development of type 2 diabetes. Pre-diabetes extendsthe definition of impaired glucose tolerance to include individuals witha fasting blood glucose within the high normal range 100 mg/dL (J. B.Meigs, et al. Diabetes 2003; 52:1475-1484) and fasting hyperinsulinemia(elevated plasma insulin concentration). The scientific and medicalbasis for identifying pre-diabetes as a serious health threat is laidout in a Position Statement entitled “The Prevention or Delay of Type 2Diabetes” issued jointly by the American Diabetes Association and theNational Institute of Diabetes and Digestive and Kidney Diseases(Diabetes Care 2002; 25:742-749).

Individuals likely to have insulin resistance are those who have two ormore of the following attributes: 1) overweight or obese, 2) high bloodpressure, 3) hyperlipidemia, 4) one or more 1^(st) degree relative witha diagnosis of IGT or IFG or type 2 diabetes. Insulin resistance can beconfirmed in these individuals by calculating the HOMA-IR score. For thepurpose of this invention, insulin resistance is defined as the clinicalcondition in which an individual has a HOMA-IR score >4.0 or a HOMA-IRscore above the upper limit of normal as defined for the laboratoryperforming the glucose and insulin assays.

The term “type 2 diabetes” is defined as the condition in which asubject has a fasting blood glucose or serum glucose concentrationgreater than 125 mg/dL (6.94 mmol/L). The measurement of blood glucosevalues is a standard procedure in routine medical analysis. If a glucosetolerance test is carried out, the blood sugar level of a diabetic willbe in excess of 200 mg of glucose per dL (11.1 mmol/l) of plasma 2 hoursafter 75 g of glucose have been taken on an empty stomach. In a glucosetolerance test 75 g of glucose are administered orally to the patientbeing tested after 10-12 hours of fasting and the blood sugar level isrecorded immediately before taking the glucose and 1 and 2 hours aftertaking it. In a healthy subject, the blood sugar level before taking theglucose will be between 60 and 110 mg per dL of plasma, less than 200 mgper dL 1 hour after taking the glucose and less than 140 mg per dL after2 hours. If after 2 hours the value is between 140 and 200 mg, this isregarded as abnormal glucose tolerance.

The term “late stage type 2 diabetes mellitus” includes type 2 diabetespatients with a secondary antidiabetic drug failure, indication forinsulin therapy and progression to micro- and macrovascularcomplications e.g. diabetic nephropathy, or coronary heart disease(CHD).

The term “HbA1c” refers to the product of a non-enzymatic glycation ofthe haemoglobin B chain. Its determination is well known to one skilledin the art. In monitoring the treatment of diabetes mellitus the HbA1cvalue is of exceptional importance. As its production dependsessentially on the blood sugar level and the life of the erythrocytes,the HbA1c in the sense of a “blood sugar memory” reflects the averageblood sugar levels of the preceding 4-6 weeks. Diabetic patients whoseHbA1c value is consistently well adjusted by intensive diabetestreatment (i.e. <6.5% of the total haemoglobin in the sample), aresignificantly better protected against diabetic microangiopathy. Forexample, metformin on its own achieves an average improvement in theHbA1c value in the diabetic of the order of 1.001.5%. This reduction ofthe HbA1C value is not sufficient in all diabetics to achieve thedesired target range of <6.5% and preferably <6% HbA1c.

The term “insufficient glycemic control” or “inadequate glycemiccontrol” in the scope of the present invention means a condition whereinpatients show HbA1c values above 6.5%, in particular above 7.0%, evenmore preferably above 7.5%, especially above 8%.

The “metabolic syndrome”, also called “syndrome X” (when used in thecontext of a metabolic disorder), also called the “dysmetabolicsyndrome” is a syndrome complex with the cardinal feature being insulinresistance (Laaksonen D E, et al. Am J Epidemiol 2002; 156:1070-7).According to the ATP III/NCEP guidelines (Executive Summary of the ThirdReport of the National Cholesterol Education Program (NCEP) Expert Panelon Detection, Evaluation, and Treatment of High Blood Cholesterol inAdults (Adult Treatment Panel III) JAMA: Journal of the American MedicalAssociation (2001) 285:2486-2497), diagnosis of the metabolic syndromeis made when three or more of the following risk factors are present:

-   -   1. Abdominal obesity, defined as waist circumference >40 inches        or 102 cm in men, and >35 inches or 94 cm in women; or with        regard to a Japanese ethnicity or Japanese patients defined as        waist circumference ≥85 cm in men and ≥90 cm in women;    -   2. Triglycerides: ≥150 mg/dL    -   3. HDL-cholesterol <40 mg/dL in men    -   4. Blood pressure ≥130/85 mm Hg (SBP ≥130 or DBP ≥85)    -   5. Fasting blood glucose ≥110 mg/dL or ≥100 mg/dL

The NCEP definitions have been validated (Laaksonen D E, et al. Am JEpidemiol. (2002) 156:1070-7). Triglycerides and HDL cholesterol in theblood can also be determined by standard methods in medical analysis andare described for example in Thomas L (Editor): “Labor and Diagnose”,TH-Books Verlagsgesellschaft mbH, Frankfurt/Main, 2000.

According to a commonly used definition, hypertension is diagnosed ifthe systolic blood pressure (SBP) exceeds a value of 140 mm Hg anddiastolic blood pressure (DBP) exceeds a value of 90 mm Hg. If a patientis suffering from manifest diabetes it is currently recommended that thesystolic blood pressure be reduced to a level below 130 mm Hg and thediastolic blood pressure be lowered to below 80 mm Hg.

The definitions of NODAT (new onset diabetes after transplantation) andPTMS (post-transplant metabolic syndrome) follow closely that of theAmerican Diabetes Association diagnostic criteria for type 2 diabetes,and that of the International Diabetes Federation (IDF) and the AmericanHeart Association/National Heart, Lung, and Blood Institute, for themetabolic syndrome. NODAT and/or PTMS are associated with an increasedrisk of micro- and macrovascular disease and events, graft rejection,infection, and death. A number of predictors have been identified aspotential risk factors related to NODAT and/or PTMS including a higherage at transplant, male gender, the pre-transplant body mass index,pre-transplant diabetes, and immunosuppression.

The term “hyperuricemia” denotes a condition of high serum total uratelevels. In human blood, uric acid concentrations between 3.6 mg/dL (ca.214 μmol/L) and 8.3 mg/dL (ca. 494 μmol/L) are considered normal by theAmerican Medical Association. High serum total urate levels, orhyperuricemia, are often associated with several maladies. For example,high serum total urate levels can lead to a type of arthritis in thejoints known as gout. Gout is a condition created by a build up ofmonosodium urate or uric acid crystals on the articular cartilage ofjoints, tendons and surrounding tissues due to elevated concentrationsof total urate levels in the blood stream. The build up of urate or uricacid on these tissues provokes an inflammatory reaction of thesetissues. Saturation levels of uric acid in urine may result in kidneystone formation when the uric acid or urate crystallizes in the kidney.Additionally, high serum total urate levels are often associated withthe so-called metabolic syndrome, including cardiovascular disease andhypertension.

The term “DPP-4 inhibitor” in the scope of the present invention relatesto a compound that exhibits inhibitory activity on the enzyme dipeptidylpeptidase IV (DPP-4). Such inhibitory activity can be characterised bythe IC50 value. A DPP-4 inhibitor preferably exhibits an IC50 valuebelow 10000 nM, preferably below 1000 nM. Certain DPP-4 inhibitorsexhibit an IC50 value below 100 nM, or even ≤50 nM. IC50 values of DPP-4inhibitors are usually above 0.01 nM, or even above 0.1 nM. DPP-IVinhibitors may include biologic and non-biologic, in particularnon-peptidic compounds. The inhibitory effect on DPP-4 can be determinedby methods known in the literature, in particular as described in theapplication WO 02/068420 or WO 2004/018468 (page 34), which areincorporated herein by reference in its entirety. The term “DPP-4inhibitor” also comprises any pharmaceutically acceptable salts thereof,hydrates and solvates thereof, including the respective crystallineforms.

The terms “treatment” and “treating” or ananlogous terms compriseparticularly therapeutic treatment of patients having already developedsaid condition, in particular in manifest form. Therapeutic treatmentmay be symptomatic treatment in order to relieve the symptoms of thespecific indication or causal treatment in order to reverse or partiallyreverse the conditions of the indication or to stop or slow downprogression of the disease. Thus the compositions and methods of thepresent invention may be used for instance as therapeutic treatment overa period of time as well as for chronic therapy.

The terms “prophylactically treating”, “preventive treating” and“preventing” or ananlogous terms are used interchangeably and comprise atreatment of patients at risk to develop a condition mentionedhereinbefore, thus reducing said risk.

DETAILED DESCRIPTION

The aspects of the present invention, in particular the pharmaceuticalcompounds, compositions, combinations, methods and uses, refer to DPP-4inhibitors, second and/or third antidiabetic agents as definedhereinbefore and hereinafter.

In a first embodiment (embodiment A), a DPP-4 inhibitor in the contextof the present invention is any DPP-4 inhibitor of

wherein R1 denotes ([1,5]naphthyridin-2-yl)methyl,(quinazolin-2-yl)methyl, (quinoxalin-6-yl)methyl,(4-methyl-quinazolin-2-yl)methyl, 2-cyano-benzyl,(3-cyano-quinolin-2-yl)methyl, (3-cyano-pyridin-2-yl)methyl,(4-methyl-pyrimidin-2-yl)methyl, or (4,6-dimethyl-pyrimidin-2-yl)methyland R2 denotes 3-(R)-amino-piperidin-1-yl,(2-amino-2-methyl-propyl)-methylamino or(2-(S)-amino-propyl)-methylamino,

or its pharmaceutically acceptable salt.

In a second embodiment (embodiment B), a DPP-4 inhibitor in the contextof the present invention is a DPP-4 inhibitor selected from the groupconsisting of

sitagliptin, vildagliptin, saxagliptin, alogliptin, gemigliptin,

(2S)-1-{([2-(5-Methyl-2-phenyl-oxazol-4-yl)-ethylamino]-acetyl}-pyrrolidine-2-carbonitrile,

(2S)-1-{[1,1,-Dimethyl-3-(4-pyridin-3-yl-imidazol-1-yl)-propylamino]-acetyl}-pyrrolidine-2-carbonitrile,

(S)-1-((2S,3S,11bS)-2-Amino-9,10-dimethoxy-1,3,4,6,7,11b-hexahydro-2H-pyrido[2,1-a]isoquinolin-3-yl)-4-fluoromethyl-pyrrolidin-2-one,

(3,3-Difluoropyrrolidin-1-yl)-((2S,4S)-4-(4-(pyrimidin-2-yl)piperazin-1-yl)pyrrolidin-2-yl)methanone,

(1((3S,4S)-4-amino-1-(4-(3,3-difluoropyrrolidin-1-yl)-1,3,5-triazin-2-yl)pyrrolidin-3-yl)-5,5-difluoropiperidin-2-one,

(2S,4S)-1-{2-[(3S,1R)-3-(1H-1,2,4-Triazol-1-ylmethyl)cyclopentylamino]-acetyl}-4-fluoropyrrolidine-2-carbonitrile,

(R)-2-[6-(3-Amino-piperidin-1-yl)-3-methyl-2,4-dioxo-3,4-dihydro-2H-pyrimidin-1-ylmethyl]-4-fluoro-benzonitrile,

5-{(S)-2-[2-((S)-2-Cyano-pyrrolidin-1-yl)-2-oxo-ethylamino]-propyl}-5-(1H-tetrazol-5-yl)-10,11-dihydro-5H-dibenzo[a,d]cycloheptene-2,8-dicarboxylicacid bis-dimethylamide,

3-{(2S,4S)-4-[4-(3-Methyl-1-phenyl-1H-pyrazol-5-yl)piperazin-1-yl]pyrrolidin-2-ylcarbonyl}thiazolidine,

[(2R)-1-{[(3R)-pyrrolidin-3-ylamino]acetyl}pyrrolidin-2-yl]boronic acid,

(2S,4S)-1-[2-[(4-ethoxycarbonylbicyclo[2.2.2]oct-1-yl)amino]acetyl]-4-fluoropyrrolidine-2-carbonitrile,

2-({6-[(3R)-3-amino-3-methylpiperidin-1-yl]-1,3-dimethyl-2,4-dioxo-1,2,3,4-tetrahydro-5H-pyrrolo[3,2-d]pyrimidin-5-yl}methyl)-4-fluorobenzonitrile,

6-[(3R)-3-amino-piperidin-1-yl]-5-(2-chloro-5-fluoro-benzyl)-1,3-dimethyl-1,5-dihydro-pyrrolo[3,2-d]pyrimidine-2,4-dione,and

(S)-2-methylpyrazolo[1,5-a]primidine-6-carboxylic acid{(2-[(2-cyanopyrrolidin-1-yl)-2-oxoethylamino]-2-methylpropyl}amide,

or its pharmaceutically acceptable salt.

Regarding the first embodiment (embodiment A), preferred DPP-4inhibitors are any or all of the following compounds and theirpharmaceutically acceptable salts:

-   -   1-[(4-methyl-quinazolin-2-yl)methyl]-3-methyl-7-(2-butyn-1-yl)-8-(3-(R)-amino-piperidin-1-yl)-xanthine        (compare WO 2004/018468, example 2(142)):

-   -   1-[([1,5]naphthyridin-2-yl)methyl]-3-methyl-7-(2-butyn-1-yl)-8-((R)-3-amino-piperidin-1-yl)-xanthine        (compare WO 2004/018468, example 2(252)):

-   -   1-[(Quinazolin-2-yl)methyl]-3-methyl-7-(2-butyn-1-yl)-8-((R)-3-amino-piperidin-1-yl)-xanthine        (compare WO 2004/018468, example 2(80)):

-   -   2-((R)-3-Amino-piperidin-1-yl)-3-(but-2-yinyl)-5-(4-methyl-quinazolin-2-ylmethyl)-3,5-dihydro-imidazo[4,5-d]pyridazin-4-one        (compare WO 2004/050658, example 136):

-   -   1-[(4-Methyl-quinazolin-2-yl)methyl]-3-methyl-7-(2-butyin-1-yl)-8-[(2-amino-2-methyl-propyl)-methylamino]-xanthine        (compare WO 2006/029769, example 2(1)):

-   -   1-[(3-Cyano-quinolin-2-yl)methyl]-3-methyl-7-(2-butyn-1-yl)-8-((R)-3-amino-piperidin-1-yl)-xanthine        (compare WO 2005/085246, example 1(30)):

-   -   1-(2-Cyano-benzyl)-3-methyl-7-(2-butyn-1-yl)-8-((R)-3-amino-piperidin-1-yl)-xanthine        (compare WO 2005/085246, example 1(39)):

-   -   1-[(4-Methyl-quinazolin-2-yl)methyl]-3-methyl-7-(2-butyn-1-yl)-8-[(S)-(2-amino-propyl)-methylamino]-xanthine        (compare WO 2006/029769, example 2(4)):

-   -   1-[(3-Cyano-pyridin-2-yl)methyl]-3-methyl-7-(2-butyn-1-yl)-8-((R)-3-amino-piperidin-1-yl)-xanthine        (compare WO 2005/085246, example 1(52)):

-   -   1-[(4-Methyl-pyrimidin-2-yl)methyl]-3-methyl-7-(2-butyn-1-yl)-8-((R)-3-amino-piperidin-1-yl)-xanthine        (compare WO 2005/085246, example 1(81)):

-   -   1-[(4,6-Dimethyl-pyrimidin-2-yl)methyl]-3-methyl-7-(2-butyn-1-yl)-8-((R)-3-amino-piperidin-1-yl)-xanthine        (compare WO 2005/085246, example 1(82)):

-   -   1-[(Quinoxalin-6-yl)methyl]-3-methyl-7-(2-butyn-1-yl)-8-((R)-3-amino-piperidin-1-yl)-xanthine        (compare WO 2005/085246, example 1(83)):

A more preferred DPP-4 inhibitor among the abovementioned DPP-4inhibitors of embodiment A of this invention is1-[(4-methyl-quinazolin-2-yl)methyl]-3-methyl-7-(2-butyn-1-yl)-8-(3-(R)-amino-piperidin-1-yl)-xanthine,particularly the free base thereof (which is also known as linagliptinor BI 1356).

As further DPP-4 inhibitors the following compounds can be mentioned:

-   -   Sitagliptin (MK-0431) having the structural formula A below is        (3R)-3-amino-1-[3-(trifluoromethyl)-5,6,7,8-tetrahydro-5H-[1,2,4]triazolo[4,3-a]pyrazin-7-yl]-4-(2,4,5-trifluorophenyl)butan-1-one,        also named        (2R)-4-oxo-4-[3-(trifluoromethyl)-5,6-dihydro[1,2,4]triazolo[4,3-a]pyrazin-7(8H)-yl]-1-(2,4,5-trifluorophenyl)butan-2-amine,

In one embodiment, sitagliptin is in the form of its dihydrogenphosphatesalt, i.e. sitagliptin phosphate. In a further embodiment, sitagliptinphosphate is in the form of a crystalline anhydrate or monohydrate. Aclass of this embodiment refers to sitagliptin phosphate monohydrate.Sitagliptin free base and pharmaceutically acceptable salts thereof aredisclosed in U.S. Pat. No. 6,699,871 and in Example 7 of WO 03/004498.Crystalline sitagliptin phosphate monohydrate is disclosed in WO2005/003135 and in WO 2007/050485.

For details, e.g. on a process to manufacture, to formulate or to usethis compound or a salt thereof, reference is thus made to thesedocuments.

A tablet formulation for sitagliptin is commercially available under thetrade name Januvia®. A tablet formulation for sitagliptin/metformincombination is commercially available under the trade name Janumet®.

-   -   Vildagliptin (LAF-237) having the structural formula B below is        (2S)-{[(3-hydroxyadamantan-1-yl)amino]acetyl}pyrrolidine-2-carbonitrile,        also named        (S)-1-[(3-hydroxy-1-adamantyl)amino]acetyl-2-cyano-pyrrolidine,

Vildagliptin is specifically disclosed in U.S. Pat. No. 6,166,063 and inExample 1 of WO 00/34241. Specific salts of vildagliptin are disclosedin WO 2007/019255. A crystalline form of vildagliptin as well as avildagliptin tablet formulation are disclosed in WO 2006/078593.

Vildagliptin can be formulated as described in WO 00/34241 or in WO2005/067976. A modified release vildagliptin formulation is described inWO 2006/135723.

For details, e.g. on a process to manufacture, to formulate or to usethis compound or a salt thereof, reference is thus made to thesedocuments.

A tablet formulation for vildagliptin is commercially available underthe trade name Galvus®.

A tablet formulation for vildagliptin/metformin combination iscommercially available under the trade name Eucreas®.

-   -   Saxagliptin (BMS-477118) having the structural formula C below        is        (1S,3S,5S)-2-{(2S)-2-amino-2-(3-hydroxyadamantan-1-yl)acetyl}-2-azabicyclo[3.1.0]hexane-3-carbonitrile,        also named        (S)-3-hydroxyadamantylglycine-L-cis-4,5-methanoprolinenitrile,

Saxagliptin is specifically disclosed in U.S. Pat. No. 6,395,767 and inExample 60 of WO 01/68603.

In one embodiment, saxagliptin is in the form of its HCl salt or itsmono-benzoate salt as disclosed in WO 2004/052850. In a furtherembodiment, saxagliptin is in the form of the free base. In a yetfurther embodiment, saxagliptin is in the form of the monohydrate of thefree base as disclosed in WO 2004/052850. Crystalline forms of the HClsalt and of the free base of saxagliptin are disclosed in WO2008/131149. A process for preparing saxagliptin is also disclosed in WO2005/106011 and WO 2005/115982. Saxagliptin can be formulated in atablet as described in WO 2005/117841.

For details, e.g. on a process to manufacture, to formulate or to usethis compound or a salt thereof, reference is thus made to thesedocuments.

-   -   Alogliptin (SYR-322) having the structural formula E below is        2-({6-[(3R)-3-aminopiperidin-1-yl]-3-methyl-2,4-dioxo-3,4-dihydro-2H-pyrimidin-1-yl}methyl)benzonitrile

Alogliptin is specifically disclosed in US 2005/261271, EP 1586571 andin WO 2005/095381. In one embodiment, alogliptin is in the form of itsbenzoate salt, its hydrochloride salt or its tosylate salt each asdisclosed in WO 2007/035629. A class of this embodiment refers toalogliptin benzoate. Polymorphs of alogliptin benzoate are disclosed inWO 2007/035372. A process for preparing alogliptin is disclosed in WO2007/112368 and, specifically, in WO 2007/035629. Alogliptin (namely itsbenzoate salt) can be formulated in a tablet and administered asdescribed in WO 2007/033266. A solid preparation ofalogliptin/pioglitazone and its preparation and use is described in WO2008/093882. A solid preparation of alogliptin/metformin and itspreparation and use is described in WO 2009/011451.

For details, e.g. on a process to manufacture, to formulate or to usethis compound or a salt thereof, reference is thus made to thesedocuments.

-   -   (2S)-1-{([2-(5-Methyl-2-phenyl-oxazol-4-yl)-ethylamino]-acetyl}-pyrrolidine-2-carbonitrile        or a pharmaceutically acceptable salt thereof, preferably the        mesylate, or

(2S)-1-{([1,1,-Dimethyl-3-(4-pyridin-3-yl-imidazol-1-yl)-propylamino]-acetyl}-pyrrolidine-2-carbonitrileor a pharmaceutically acceptable salt thereof:

These compounds and methods for their preparation are disclosed in WO03/037327.

The mesylate salt of the former compound as well as crystallinepolymorphs thereof are disclosed in WO 2006/100181. The fumarate salt ofthe latter compound as well as crystalline polymorphs thereof aredisclosed in WO 2007/071576. These compounds can be formulated in apharmaceutical composition as described in WO 2007/017423.

For details, e.g. on a process to manufacture, to formulate or to usethese compounds or salts thereof, reference is thus made to thesedocuments.

-   -   (S)-1-((2S,3S,11bS)-2-Amino-9,10-dimethoxy-1,3,4,6,7,11b-hexahydro-2H-pyrido[2,1-a]isoquinolin-3-yl)-4-fluoromethyl-pyrrolidin-2-one        (also named carmegliptin) or a pharmaceutically acceptable salt        thereof:

This compound and methods for its preparation are disclosed in WO2005/000848. A process for preparing this compound (specifically itsdihydrochloride salt) is also disclosed in WO 2008/031749, WO2008/031750 and WO 2008/055814. This compound can be formulated in apharmaceutical composition as described in WO 2007/017423.

For details, e.g. on a process to manufacture, to formulate or to usethis compound or a salt thereof, reference is thus made to thesedocuments.

-   -   (3,3-Difluoropyrrolidin-1-yl)-((2S,4S)-4-(4-(pyrimidin-2-yl)piperazin-1-yl)pyrrolidin-2-yl)methanone        (also named gosogliptin) or a pharmaceutically acceptable salt        thereof:

This compound and methods for its preparation are disclosed in WO2005/116014 and U.S. Pat. No. 7,291,618.

For details, e.g. on a process to manufacture, to formulate or to usethis compound or a salt thereof, reference is thus made to thesedocuments.

-   -   (1((3S,4S)-4-amino-1-(4-(3,3-difluoropyrrolidin-1-yl)-1,3,5-triazin-2-yl)pyrrolidin-3-yl)-5,5-difluoropiperidin-2-one        or a pharmaceutically acceptable salt thereof:

This compound and methods for its preparation are disclosed in WO2007/148185 and US 20070299076. For details, e.g. on a process tomanufacture, to formulate or to use this compound or a salt thereof,reference is thus made to these documents.

-   -   (2S,4S)-1-{2-[(35,1R)-3-(1H-1,2,4-Triazol-1-ylmethyl)cyclopentylamino]-acetyl}-4-fluoropyrrolidine-2-carbonitrile        (also named melogliptin) or a pharmaceutically acceptable salt        thereof:

This compound and methods for its preparation are disclosed in WO2006/040625 and WO 2008/001195. Specifically claimed salts include themethanesulfonate and p-toluenesulfonate. For details, e.g. on a processto manufacture, to formulate or to use this compound or a salt thereof,reference is thus made to these documents.

-   -   (R)-2-[6-(3-Amino-piperidin-1-yl)-3-methyl-2,4-dioxo-3,4-dihydro-2H-pyrimidin-1-ylmethyl]-4-fluoro-benzonitrile        or a pharmaceutically acceptable salt thereof:

This compound and methods for its preparation and use are disclosed inWO 2005/095381, US 2007060530, WO 2007/033350, WO 2007/035629, WO2007/074884, WO 2007/112368, WO 2008/033851, WO 2008/114800 and WO2008/114807. Specifically claimed salts include the succinate (WO2008/067465), benzoate, benzenesulfonate, p-toluenesulfonate,(R)-mandelate and hydrochloride. For details, e.g. on a process tomanufacture, to formulate or to use this compound or a salt thereof,reference is thus made to these documents.

-   -   5-{(S)-2-[2-((S)-2-Cyano-pyrrolidin-1-yl)-2-oxo-ethylamino]-propyl}-5-(1H-tetrazol-5-yl)-10,11-dihydro-5H-dibenzo[a,d]cycloheptene-2,8-dicarboxylic        acid bis-dimethylamide or a pharmaceutically acceptable salt        thereof:

This compound and methods for its preparation are disclosed in WO2006/116157 and US 2006/270701. For details, e.g. on a process tomanufacture, to formulate or to use this compound or a salt thereof,reference is thus made to these documents.

-   -   3-{(2S,4S)-4-[4-(3-Methyl-1-phenyl-1H-pyrazol-5-yl)piperazin-1-yl]pyrrolidin-2-ylcarbonyl}thiazolidine        (also named teneligliptin) or a pharmaceutically acceptable salt        thereof:

This compound and methods for its preparation are disclosed in WO02/14271. Specific salts are disclosed in WO 2006/088129 and WO2006/118127 (including hydrochloride, hydrobromide, inter alia).Combination therapy using this compound is described in WO 2006/129785.For details, e.g. on a process to manufacture, to formulate or to usethis compound or a salt thereof, reference is thus made to thesedocuments.

-   -   [(2R)-1-{[(3R)-pyrrolidin-3-ylamino]acetyl}pyrrolidin-2-yl]boronic        acid (also named dutogliptin) or a pharmaceutically acceptable        salt thereof:

This compound and methods for its preparation are disclosed in WO2005/047297, WO 2008/109681 and WO 2009/009751. Specific salts aredisclosed in WO 2008/027273 (including citrate, tartrate). A formulationof this compound is described in WO 2008/144730. A formulation ofdutogliptin (as its tartrate salt) with metformin is described in WO2009/091663. For details, e.g. on a process to manufacture, to formulateor to use this compound or a salt thereof, reference is thus made tothese documents.

-   -   (2S,4S)-1-[2-[(4-ethoxycarbonylbicyclo[2.2.2]oct-1-yl)amino]acetyl]-4-fluoropyrrolidine-2-carbonitrile        or a pharmaceutically acceptable salt thereof:

This compound and methods for its preparation are disclosed in WO2005/075421, US 2008/146818 and WO 2008/114857. For details, e.g. on aprocess to manufacture, to formulate or to use this compound or a saltthereof, reference is thus made to these documents.

-   -   2-({6-[(3R)-3-amino-3-methylpiperidin-1-yl]-1,3-dimethyl-2,4-dioxo-1,2,3,4-tetrahydro-5H-pyrrolo[3,2-d]pyrimidin-5-yl}methyl)-4-fluorobenzonitrile        or a pharmaceutically acceptable salt thereof, or        6-[(3R)-3-amino-piperidin-1-yl]-5-(2-chloro-5-fluoro-benzyl)-1,3-dimethyl-1,5-dihydro-pyrrolo[3,2-d]pyrimidine-2,4-dione        or a pharmaceutically acceptable salt thereof:

These compounds and methods for their preparation are disclosed in WO2009/084497 and WO 2006/068163, respectively. Combination therapy usingthe latter of these two compounds is described in WO 2009/128360. Fordetails, e.g. on a process to manufacture, to formulate or to use thesecompounds or salts thereof, reference is thus made to these documents.

-   -   (S)-2-methylpyrazolo[1,5-a]primidine-6-carboxylic acid        {(2-[(2-cyanopyrrolidin-1-yl)-2-oxoethylamino]-2-methylpropyl}amide        (also named anagliptin) or a pharmaceutically acceptable salt:

This compound and methods for its preparation are disclosed in WO2004/067509. Combination therapy using this compound is described in WO2009/139362. For details, e.g. on a process to manufacture, to formulateor to use this compound or a salt thereof, reference is thus made tothese documents.

Preferably the DPP-4 inhibitor is selected from the group G2 consistingof linagliptin, sitagliptin, vildagliptin, alogliptin, saxagliptin,carmegliptin, gosogliptin, teneligliptin, melogliptin and dutogliptin,or a pharmaceutically acceptable salt of one of the hereinmentionedDPP-4 inhibitors, or a prodrug thereof.

More preferably the DPP-4 inhibitor is selected from the group G2consisting of linagliptin, sitagliptin, vildagliptin, alogliptin,saxagliptin, teneligliptin and dutogliptin, or a pharmaceuticallyacceptable salt of one of the hereinmentioned DPP-4 inhibitors, or aprodrug thereof.

A particularly preferred DPP-4 inhibitor within the present invention islinagliptin. The term “linagliptin” as employed herein refers tolinagliptin and pharmaceutically acceptable salts thereof, includinghydrates and solvates thereof, and crystalline forms thereof.Crystalline forms are described in WO 2007/128721. Methods for themanufacture of linagliptin are described in the patent applications WO2004/018468 and WO 2006/048427 for example. Linagliptin is distinguishedfrom structurally comparable DPP-4 inhibitors, as it combinesexceptional potency and a long-lasting effect with favourablepharmacological properties, receptor selectivity and a favourableside-effect profile or bring about unexpected therapeutic advantages orimprovements in monotherapy and/or when used in combination with asecond and, optionally, a third antidiabetic agent according to thisinvention.

For avoidance of any doubt, the disclosure of each of the foregoingdocuments cited above in connection with the specified DPP-4 inhibitorsis specifically incorporated herein by reference in its entirety.

In one aspect of the present invention, the pharmaceutical compositions,methods and uses according to this invention relate to thosecompositions which comprise the DPP-4 inhibitor as sole activeingredient (i.e. the second and third antidiabetic agent are bothabsent) and/or, respectively, to monotherapy using the DPP-4 inhibitoralone.

In another aspect of the present invention, the pharmaceuticalcompositions, combinations, methods and uses according to this inventionrelate to those compositions or combinations which comprise the DPP-4inhibitor and the second antidiabetic agent as sole active ingredients(i.e. the third antidiabetic agent is absent) and/or, respectively, todual combination therapy using the DPP-4 inhibitor and the secondantidiabetic agent.

In another aspect of the present invention, the pharmaceuticalcompositions, combinations, methods and uses according to this inventionrelate to those compositions or combinations which comprise the DPP-4inhibitor, the second and the third antidiabetic agent and/or,respectively, to triple combination therapy using the DPP-4 inhibitor,the second and the third antidiabetic agent.

Further, a DPP-4 inhibitor according to this invention may be furthercharacterized in that said DPP-4 inhibitor does not significantly impairglomerular and/or tubular function of a type 2 diabetes patient withchronic renal insufficiency (e.g. mild, moderate or severe renalimpairment or end stage renal disease), and/or

said DPP-4 inhibitor does not require to be dose-adjusted in a type 2diabetes patient with impaired renal function (e.g. mild, moderate orsevere renal impairment or end stage renal disease).

The second antidiabetic agent and, if present, the third antidiabeticagent is selected from the group G3 consisting of biguanides,thiazolidindiones, sulfonylureas, glinides, inhibitors ofalpha-glucosidase, GLP-1 or GLP-1 analogues, and insulin or insulinanalogues, or a pharmaceutically acceptable salt thereof. In thefollowing preferred embodiments regarding the second and/or the thirdantidiabetic agent are described.

The group G3 comprises biguanides. Examples of biguanides are metformin,phenformin and buformin. A preferred biguanide is metformin. A DPP-4inhibitor in combination with a biguanide, in particular metformin, canprovide more efficacious glycemic control and/or may act together withthe biguanide, for example to reduce weight, that has e.g. overallbeneficial effects on the metabolic syndrome which is commonlyassociated with type 2 diabetes mellitus.

The term “metformin” as employed herein refers to metformin or apharmaceutically acceptable salt thereof such as the hydrochloride salt,the metformin (2:1) fumarate salt, and the metformin (2:1) succinatesalt, the hydrobromide salt, the p-chlorophenoxy acetate or theembonate, and other known metformin salts of mono and dibasic carboxylicacids. It is preferred that the metformin employed herein is themetformin hydrochloride salt.

The group G3 comprises thiazolidindiones. Examples of thiazolidindiones(TZD) are pioglitazone and rosiglitazone. TZD therapy is associated withweight gain and fat redistribution. In addition, TZD cause fluidretention and are not indicated in patients with congestive heartfailure. Long term treatment with TZD are further associated with anincreased risk of bone fractures. A DPP-4 inhibitor in combination witha thiazolidindione, in particular pioglitazone, can provide moreefficacious glycemic control and/or can minimize side effects of thetreatment with TZD.

The term “pioglitazone” as employed herein refers to pioglitazone,including its enantiomers, mixtures thereof and its racemate, or apharmaceutically acceptable salt thereof such as the hydrochloride salt.

The term “rosiglitazone” as employed herein refers to rosiglitazone,including its enantiomers, mixtures thereof and its racemate, or apharmaceutically acceptable salt thereof such as the maleate salt.

The group G3 comprises sulfonylureas. Examples of sulfonylureas areglibenclamide, tolbutamide, glimepiride, glipizide, gliquidone,glibornuride, glyburide, glisoxepide and gliclazide. Preferredsulfonylureas are tolbutamide, gliquidone, glibenclamide andglimepiride, in particular glibenclamide and glimepiride. As theefficacy of sulfonylureas wears off over the course of treatment, acombination of a DPP-4 inhibitor with a sulfonylurea may offeradditional benefit to the patient in terms of better glycemic control.Also, treatment with sulfonylureas is normally associated with gradualweight gain over the course of treatment and a DPP-4 inhibitor mayminimize this side effect of the treatment with an sulfonylurea and/orimprove the metabolic syndrome. Also, a DPP-4 inhibitor in combinationwith a sulfonylurea may minimize hypoglycemia which is anotherundesirable side effect of sulfonylureas. This combination may alsoallow a reduction in the dose of sulfonylureas, which may also translateinto less hypoglycemia.

Each term of the group “glibenclamide”, “glimepiride”, “gliquidone”,“glibornuride”, “gliclazide”, “glisoxepide”, “tolbutamide” and“glipizide” as employed herein refers to the respective active drug or apharmaceutically acceptable salt thereof.

The group G3 comprises glinides. Examples of glinides are nateglinide,repaglinide and mitiglinide. As their efficacy wears off over the courseof treatment, a combination of a DPP-4 inhibitor with a meglitinide mayoffer additional benefit to the patient in terms of better glycemiccontrol. Also, treatment with meglitinides is normally associated withgradual weight gain over the course of treatment and a DPP-4 inhibitormay minimize this side effect of the treatment with an meglitinideand/or improve the metabolic syndrome. Also, a DPP-4 inhibitor incombination with a meglitinide may minimize hypoglycemia which isanother undesirable side effect of meglitinides. This combination mayalso allow a reduction in the dose of meglitinides, which may alsotranslate into less hypoglycemia.

The term “nateglinide” as employed herein refers to nateglinide,including its enantiomers, mixtures thereof and its racemate, or apharmaceutically acceptable salts and esters thereof.

The term “repaglinide” as employed herein refers to repaglinide,including its enantiomers, mixtures thereof and its racemate, or apharmaceutically acceptable salts and esters thereof.

The group G3 comprises inhibitors of alpha-glucosidase. Examples ofinhibitors of alpha-glucosidase are acarbose, voglibose and miglitol.Additional benefits from the combination of a DPP-4 inhibitor and analpha-glucosidase inhibitor may relate to more efficacious glycemiccontrol, e.g. at lower doses of the individual drugs, and/or reducementof undesirable gastrointestinal side effects of alpha-glucosidaseinhibitors.

Each term of the group “acarbose”, “voglibose” and “miglitol” asemployed herein refers to the respective active drug or apharmaceutically acceptable salt thereof.

The group G3 comprises inhibitors of GLP-1 analogues. Examples of GLP-1analogues are exenatide, liraglutide, taspoglutide, semaglutide,albiglutide, and lixisenatide. The combination of a DPP-4 inhibitor anda GLP-1 analogue may achieve a superior glycemic control, e.g. at lowerdoses of the individual drugs. In addition, e.g. the body weightreducing capability of the GLP-1 analogue may be positively act togetherwith the properties of the DPP-4 inhibitor. On the other hand, areduction of side effects (e.g. nausea, gastrointestinal side effectslike vomiting) may be obtained, e.g. when a reduced dose of the GLP-1analogue is applied in the combination with a DPP-4 inhibitor.

Each term of the group “exenatide”, “liraglutide”, “taspoglutide”,“semaglutide”, “albiglutide”, and “lixisenatide” as employed hereinrefers to the respective active drug or a pharmaceutically acceptablesalt thereof.

In an embodiment (embodiment E1) the pharmaceutical compositions,combinations, methods and uses according to this invention relate tothose combinations wherein the DPP-4 inhibitor and the secondantidiabetic agent are preferably selected according to the entries inthe Table 1.

TABLE 1 DPP-4 Inhibitor Second Antidiabetic Agent selected fromembodiment B selected from the group G3 selected from embodiment BMetformin selected from embodiment B Pioglitazone selected fromembodiment B Rosiglitazone selected from embodiment B Glibenclamideselected from embodiment B Glimepiride selected from embodiment BGliquidone selected from embodiment B Nateglinide selected fromembodiment B Repaglinide selected from embodiment B Acarbose selectedfrom embodiment B Voglibose selected from embodiment B Miglitol selectedfrom embodiment B Exenatide selected from embodiment B Liraglutideselected from embodiment B Taspoglutide selected from embodiment BSemaglutide selected from embodiment B Albiglutide selected fromembodiment B Lixisenatide Linagliptin selected from the group G3Linagliptin Metformin Linagliptin Pioglitazone Linagliptin RosiglitazoneLinagliptin Glibenclamide Linagliptin Glimepiride Linagliptin GliquidoneLinagliptin Nateglinide Linagliptin Repaglinide Linagliptin AcarboseLinagliptin Voglibose Linagliptin Miglitol Linagliptin ExenatideLinagliptin Liraglutide Linagliptin Taspoglutide Linagliptin SemaglutideLinagliptin Albiglutide Linagliptin Lixisenatide Sitagliptin selectedfrom the group G3 Sitagliptin Metformin Sitagliptin PioglitazoneSitagliptin Rosiglitazone Sitagliptin Glibenclamide SitagliptinGlimepiride Sitagliptin Gliquidone Sitagliptin Nateglinide SitagliptinRepaglinide Sitagliptin Acarbose Sitagliptin Voglibose SitagliptinMiglitol Sitagliptin Exenatide Sitagliptin Liraglutide SitagliptinTaspoglutide Sitagliptin Semaglutide Sitagliptin Albiglutide SitagliptinLixisenatide Vildagliptin selected from the group G3 VildagliptinMetformin Vildagliptin Pioglitazone Vildagliptin RosiglitazoneVildagliptin Glibenclamide Vildagliptin Glimepiride VildagliptinGliquidone Vildagliptin Nateglinide Vildagliptin RepaglinideVildagliptin Acarbose Vildagliptin Voglibose Vildagliptin MiglitolVildagliptin Exenatide Vildagliptin Liraglutide VildagliptinTaspoglutide Vildagliptin Semaglutide Vildagliptin AlbiglutideVildagliptin Lixisenatide Alogliptin selected from the group G3Alogliptin Metformin Alogliptin Pioglitazone Alogliptin RosiglitazoneAlogliptin Glibenclamide Alogliptin Glimepiride Alogliptin GliquidoneAlogliptin Nateglinide Alogliptin Repaglinide Alogliptin AcarboseAlogliptin Voglibose Alogliptin Miglitol Alogliptin Exenatide AlogliptinLiraglutide Alogliptin Taspoglutide Alogliptin Semaglutide AlogliptinAlbiglutide Alogliptin Lixisenatide Saxagliptin selected from the groupG3 Saxagliptin Metformin Saxagliptin Pioglitazone SaxagliptinRosiglitazone Saxagliptin Glibenclamide Saxagliptin GlimepirideSaxagliptin Gliquidone Saxagliptin Nateglinide Saxagliptin RepaglinideSaxagliptin Acarbose Saxagliptin Voglibose Saxagliptin MiglitolSaxagliptin Exenatide Saxagliptin Liraglutide Saxagliptin TaspoglutideSaxagliptin Semaglutide Saxagliptin Albiglutide Saxagliptin LixisenatideCarmegliptin selected from the group G3 Carmegliptin MetforminCarmegliptin Pioglitazone Carmegliptin Rosiglitazone CarmegliptinGlibenclamide Carmegliptin Glimepiride Carmegliptin GliquidoneCarmegliptin Nateglinide Carmegliptin Repaglinide Carmegliptin AcarboseCarmegliptin Voglibose Carmegliptin Miglitol Carmegliptin ExenatideCarmegliptin Liraglutide Carmegliptin Taspoglutide CarmegliptinSemaglutide Carmegliptin Albiglutide Carmegliptin LixisenatideMelogliptin selected from the group G3 Melogliptin Metformin MelogliptinPioglitazone Melogliptin Rosiglitazone Melogliptin GlibenclamideMelogliptin Glimepiride Melogliptin Gliquidone Melogliptin NateglinideMelogliptin Repaglinide Melogliptin Acarbose Melogliptin VogliboseMelogliptin Miglitol Melogliptin Exenatide Melogliptin LiraglutideMelogliptin Taspoglutide Melogliptin Semaglutide Melogliptin AlbiglutideMelogliptin Lixisenatide Dutogliptin selected from the group G3Dutogliptin Metformin Dutogliptin Pioglitazone Dutogliptin RosiglitazoneDutogliptin Glibenclamide Dutogliptin Glimepiride Dutogliptin GliquidoneDutogliptin Nateglinide Dutogliptin Repaglinide Dutogliptin AcarboseDutogliptin Voglibose Dutogliptin Miglitol Dutogliptin ExenatideDutogliptin Liraglutide Dutogliptin Taspoglutide Dutogliptin SemaglutideDutogliptin Albiglutide Dutogliptin Lixisenatide Gosogliptin selectedfrom the group G3 Gosogliptin Metformin Gosogliptin PioglitazoneGosogliptin Rosiglitazone Gosogliptin Glibenclamide GosogliptinGlimepiride Gosogliptin Gliquidone Gosogliptin Nateglinide GosogliptinRepaglinide Gosogliptin Acarbose Gosogliptin Voglibose GosogliptinMiglitol Gosogliptin Exenatide Gosogliptin Liraglutide GosogliptinTaspoglutide Gosogliptin Semaglutide Gosogliptin Albiglutide GosogliptinLixisenatide Teneligliptin selected from the group G3 TeneligliptinMetformin Teneligliptin Pioglitazone Teneligliptin RosiglitazoneTeneligliptin Glibenclamide Teneligliptin Glimepiride TeneligliptinGliquidone Teneligliptin Nateglinide Teneligliptin RepaglinideTeneligliptin Acarbose Teneligliptin Voglibose Teneligliptin MiglitolTeneligliptin Exenatide Teneligliptin Liraglutide TeneligliptinTaspoglutide Teneligliptin Semaglutide Teneligliptin AlbiglutideTeneligliptin Lixisenatide

In a particular embodiment (embodiment E2) the pharmaceuticalcompositions, combinations, methods and uses according to this inventionrelate to those combinations wherein the DPP-4 inhibitor is linagliptin.According to embodiment E2 the second antidiabetic agent is preferablyselected according to the entries in the Table 2.

TABLE 2 Embodiment Second Antidiabetic Agent E2.1 selected from thegroup G3 E2.2 Metformin E2.3 Pioglitazone E2.4 Rosiglitazone E2.5Glibenclamide E2.6 Glimepiride E2.7 Gliquidone E2.8 Nateglinide E2.9Repaglinide E2.10 Acarbose E2.11 Voglibose E2.12 Miglitol E2.13Exenatide E2.14 Liraglutide E2.15 Taspoglutide E2.16 Semaglutide E2.17Albiglutide E2.18 Lixisenatide E2.19 insulin or insulin analogue E2.20GLP-1 or GLP-1 analogue

The combination of a DPP-4 inhibitor and a second and, optionally, athird antidiabetic agent according to this invention can be found toimprove the glycemic control, in particular in patients as describedherein, compared with a monotherapy using either a DPP-4 inhibitor orthe second or third antidiabetic agent alone, for example with amonotherapy of metformin, or with a dual therapy using the second andthird antidiabetic agent. Further, the triple combination of a DPP-4inhibitor and a second and a third antidiabetic agent according to thisinvention can be found to improve the glycemic control, in particular inpatients as described herein, compared with a combination therapy usinga DPP-4 inhibitor and either the second or third antidiabetic agent, orusing the second and the third antidiabetic agent. The improved glycemiccontrol is determined as an increased lowering of blood glucose and anincreased reduction of HbA1c. With monotherapy in a patient, inparticular in patients as described herein, the glycemic control may notbe further improved significantly by an administration of the drug abovea certain highest dose. In addition, a long term treatment using ahighest dose may be unwanted in view of potential side effects.Therefore, a satisfying glycemic control may not be achievable in allpatients via a monotherapy using either the DPP-4 inhibitor or thesecond or the third antidiabetic agent alone. In the case thatmonotherapy do not yield in full glycemic control, dual therapy maybecome necessary. Even with combination therapy using two agentsselected from the DPP-4 inhibitors and second and third antidiabeticagents may not yield in a full glycemic control in all patients and/orover a long time. In the case that dual therapy do not yield in fullglycemic control, triple therapy may become necessary. In such patientswith inadequate glycemic control a progression of the diabetes mellitusmay continue and complications associated with diabetes mellitus mayoccur, such as macrovascular complications. The pharmaceuticalcomposition or combination as well as the methods according to thepresent invention allow a reduction of the HbA1c value to a desiredtarget range, for example <7% and preferably <6.5%, for a higher numberof patients and for a longer time of therapeutic treatment, e.g. in thecase of dual or triple combination therapy compared with a monotherapyusing one of or, respectively, a dual therapy using two of thecombination partners.

In addition, the combination of a DPP-4 inhibitor and the second and,optionally, the third therapeutic agent according to this invention canbe found to allow a reduction in the dose of either the DPP-4 inhibitoror the second or third antidiabetic agent or even of two or three of theactive ingredients. A dose reduction is beneficial for patients whichotherwise would potentially suffer from side effects in a therapy usinga higher dose of one or more of the active ingredients, in particularwith regard to side effect caused by the second and/or thirdantidiabetic agent. Therefore, the pharmaceutical combination as well asthe methods according to the present invention, may show less sideeffects, thereby making the therapy more tolerable and improving thepatients compliance with the treatment.

A DPP-4 inhibitor according to the present invention is able—via theincreases in active GLP-1 levels—to reduce the glucagon secretion in apatient. This will therefore limit the hepatic glucose production.Furthermore, the elevated active GLP-1 levels produced by the DPP-4inhibitor will have beneficial effects on beta-cell regeneration andneogenesis. All these features of DPP-4 inhibitors may render apharmaceutical composition or combination or method of this inventionquite useful and therapeutically relevant.

When this invention refers to patients requiring treatment orprevention, it relates primarily to treatment and prevention in humans,but the pharmaceutical composition may also be used accordingly inveterinary medicine in mammals. In the scope of this invention adultpatients are preferably humans of the age of 18 years or older. Also inthe scope of this invention, patients are adolescent humans, i.e. humansof age 10 to less than 18 years, preferably of age 13 to less than 18years.

In one embodiment, patients in need of treatment or prevention asdescribed herein can be identified by determining whether they havevariation(s) (e.g. polymorphisms) in one or more genes associated withmetabolic diseases and/or whether they have variation(s) (e.g.polymorphisms) in one or more of the genes selected from TCF7L2, KCNJ11,PPARG and GLP1 R, in particular whether they are of TCF7L2 risk genotypeas described herein.

In another embodiment, patients in need of treatment or prevention asdescribed herein can be identified by determining whether they are ofrespective wild-type genotype, in particular whether they are of TCF7L2wild genotype as described herein.

A particular sub-population of the patients in need of treatment orprevention as described herein, refers to those patients who have one ormore single nucleotide polymorphisms (SNPs) in the gene coding forTCF7L2, especially a SNP selected from rs7903146, rs12255372 andrs10885406, especially rs7903146, in more particular, those patients whocarry at least one T allele of SNP rs7903146 of TCF7L2, i.e. the CTgenotype or TT genotype.

Another particular sub-population of the patients in need of treatmentor prevention as described herein, refers to those patients who carryTCF7L2 rs7903146 CC wild genotype.

Thus, in an aspect of this invention, a treatment or prophylaxisaccording to this invention is suitable in those patients in need ofsuch treatment or prophylaxis who are diagnosed of having variation(s)(e.g. polymorphisms) in one or more genes associated with metabolicdiseases and/or variation(s) (e.g. SNPs) in one or more of the genesselected from TCF7L2, KCNJ11, PPARG and GLP1 R, in particular of TCF7L2risk genotype as described herein.

In another aspect of this invention, a treatment or prophylaxisaccording to this invention is particular suitable in those patients inneed of such treatment or prophylaxis who are diagnosed of having TCF7L2wild genotype as described herein.

In an sub-aspect of this invention, a treatment or prophylaxis accordingto this invention is suitable in those patients in need of suchtreatment or prophylaxis who are diagnosed of having one or more singlenucleotide polymorphisms (SNPs) in the gene coding for TCF7L2, e.g. atleast one SNP selected from rs7903146, rs12255372 and rs10885406, forexample rs7903146, in particular, carrying at least one T allele ofrs7903146, (i.e. of CT or TT genotype), among them, in more particular,those carrying one T allele of rs7903146 (i.e. of CT risk genotype) or,in less particular, those carrying two T alleles of rs7903146 (i.e. ofTT high risk genotype).

In another sub-aspect of this invention, a treatment or prophylaxisaccording to this invention is particular favorable in those patients inneed of such treatment or prophylaxis who are diagnosed of carryingwild-type two C alleles of rs7903146 in TCF7L2 (i.e. of CC genotype).

In an embodiment of this invention, a treatment or prophylaxis accordingto this invention is suitable in those patients in need of suchtreatment or prophylaxis who are diagnosed of one or more of theconditions selected from the group consisting of overweight and obesity,in particular class I obesity, class II obesity, class III obesity,visceral obesity and abdominal obesity. In addition a treatment orprophylaxis according to this invention is advantageously suitable inthose patients in which a weight increase is contraindicated. Any weightincreasing effect in the therapy, for example due to the administrationof the second and/or third antidiabetic agent, may be attenuated or evenavoided thereby.

In a further embodiment of this invention, the pharmaceuticalcomposition or combination of this invention exhibits a very goodefficacy with regard to glycemic control, in particular in view of areduction of fasting plasma glucose, postprandial plasma glucose and/orglycosylated hemoglobin (HbA1c). By administering a pharmaceuticalcomposition or combination according to this invention, a reduction ofHbA1c equal to or greater than preferably 1.0%, more preferably equal toor greater than 2.0%, even more preferably equal to or greater than 3.0%can be achieved and the reduction is particularly in the range from 1.0%to 3.0%.

Furthermore, the method and/or use according to this invention isapplicable in those patients who show one, two or more of the followingconditions:

-   -   (a) a fasting blood glucose or serum glucose concentration        greater than 110 mg/dL or greater than 100 mg/dL, in particular        greater than 125 mg/dL;    -   (b) a postprandial plasma glucose equal to or greater than 140        mg/dL;    -   (c) an HbA1c value equal to or greater than 6.5%, in particular        equal to or greater than 7.0%, especially equal to or greater        than 7.5%, even more particularly equal to or greater than 8.0%.

The present invention also discloses the use of the pharmaceuticalcomposition or combination for improving glycemic control in patientshaving type 2 diabetes or showing first signs of pre-diabetes. Thus, theinvention also includes diabetes prevention. If therefore apharmaceutical composition or combination of this invention is used toimprove the glycemic control as soon as one of the above-mentioned signsof pre-diabetes is present, the onset of manifest type 2 diabetesmellitus can be delayed or prevented.

Furthermore, the pharmaceutical composition or combination of thisinvention is particularly suitable in the treatment of patients withinsulin dependency, i.e. in patients who are treated or otherwise wouldbe treated or need treatment with an insulin or a derivative of insulinor a substitute of insulin or a formulation comprising an insulin or aderivative or substitute thereof. These patients include patients withdiabetes type 2 and patients with diabetes type 1.

Therefore, according to an embodiment of the present invention, there isprovided a method for improving glycemic control and/or for reducing offasting plasma glucose, of postprandial plasma glucose and/or ofglycosylated hemoglobin HbA1c in a patient in need thereof who isdiagnosed with impaired glucose tolerance (IGT), impaired fasting bloodglucose (IFG) with insulin resistance, with metabolic syndrome and/orwith type 2 or type 1 diabetes mellitus characterized in that a DPP-4inhibitor and, optionally, a second and, optionally, a thirdantidiabetic agent as defined hereinbefore and hereinafter areadministered, for example in combination, to the patient.

According to another embodiment of the present invention, there isprovided a method for improving gycemic control in patients, inparticular in adult patients, with type 2 diabetes mellitus as anadjunct to diet and exercise.

Moreover, in a particular embodiment of this invention, a therapeutic orpreventive method and/or use according to this invention is suitable inthose patients who have variation(s) (e.g. polymorphisms) in one or moregenes associated with metabolic diseases and/or who have variation(s)(e.g. polymorphisms) in one or more of the genes selected from TCF7L2,KCNJ11, PPARG and GLP1 R.

In this context, a sub-population of the patients described hereinbeforeand hereinafter refers to TCF7L2 risk genotype patients, such as e.g. tothose patients who have one or more single nucleotide polymorphisms(SNPs) in the gene coding for TCF7L2, especially at least one SNPselected from rs7903146, rs12255372 and rs10885406, especiallyrs7903146. In more particular, those patients who carry at least one Tallele of SNP rs7903146 of TCF7L2, i.e. the CT genotype or TT genotype,especially who carry two T alleles of SNP rs7903146 of TCF7L2, i.e. theTT genotype, are strongly susceptible to increased TCF7L2 expression inpancreatic beta cells, impaired insulin secretion, incretine effects,enhanced rate of hepatic glucose production and/or diabetes. The Tallele of rs7903146 TCF7L2 is associated with impaired insulinotropicaction of incretin hormones, reduced 24 h profiles of plasma insulin andglucagon, and increased hepatic glucose production.

Therefore, the present invention also includes the compounds,pharmaceutical compositions or combinations according to this inventionfor use in the treatment and/or prevention of those diseases, disordersor conditions mentioned herein in those patients who have one or moresingle nucleotide polymorphisms (SNPs) in the gene coding for TCF7L2,especially at least one SNP selected from rs7903146, rs12255372 andrs10885406, especially rs7903146; in more particular, in those patientswho carry at least one T allele of SNP rs7903146 of TCF7L2, i.e. the CTgenotype or TT genotype, particularly in those patients who carry one Tallele of SNP rs7903146 of TCF7L2, i.e. the CT genotype, or who carrytwo T alleles of SNP rs7903146 of TCF7L2, i.e. the TT genotype.

TCF7L2 risk genotype patients as described herein include, without beinglimited, patients of Caucasian, North European, East Asian, Indianand/or African descent.

The present invention further includes a therapeutic and/or preventivemethod or use according to this invention for application in a patientin need thereof, said method or use comprising the step of determiningwhether the patient has variation(s) (e.g. polymorphisms) in one or moreof the genes selected from TCF7L2, KCNJ11, PPARG and GLP1 R,particularly whether the patient is of a TCF7L2 risk genotype asdescribed herein.

The determination or diagnosis whether the patient has variation(s)(e.g. polymorphisms) in one or more of the genes selected from TCF7L2,KCNJ11, PPARG and GLP1 R, particularly whether the patient is of aTCF7L2 risk genotype as described herein, or whether the patient is ofwild genotype, particularly whether the patient is of TCF7L2 wildgenotype as described herein, may be used for determining the likelihood(e.g., increased, decreased, or no likelihood) of a favourabletherapeutic and/or preventive response of the patient to the treatmentwith a DPP-4 inhibitor (or with a combination of a DPP-4 inhibitor withthe second and/or third antidiabetic agent as defined herein) in atherapeutic and/or preventive method or use as described hereinabove orhereinbelow (e.g. in treating diabetes or in improving glycemiccontrol), and thus for identifying a subject being susceptible to suchtreatment.

Thus, further on, in another embodiment of this invention, there isprovided a method of determining the probability of likelihood (e.g.,increased, decreased, or no likelihood) of a favourable response to theadministration of a pharmaceutically acceptable amount of a DPP-4inhibitor (or of a combination of a DPP-4 inhibitor with the secondand/or third antidiabetic agent as described herein) in a subject(particularly diabetes patient), said method comprising the step ofdetermining whether the subject has variation(s) (e.g. polymorphisms) inone or more of the genes selected from TCF7L2, KCNJ11, PPARG and GLP1 R,particularly whether the subject is of a TCF7L2 risk genotype asdescribed herein, or determining whether the subject is of TCF7L2 wildgenotype, particularly testing whether the subject is of the TCF7L2rs7903146 CC wild genotype.

According to another particular embodiment this invention, the presentinvention provides a DPP-4 inhibitor, a pharmaceutical composition orcombination according to the present invention for use in a therapeuticor preventive method as described hereinbefore or hereinafter(particularly for treating or preventing type 2 diabetes and/orobesity), said method comprising

(i) identifying a subject being susceptible to the therapeutic orpreventive method, said identifying comprising testing whether thesubject has variation(s) (e.g. polymorphisms) in one or more of thegenes selected from TCF7L2, KCNJ11, PPARG and GLP1 R, in particularwhether the subject is of any TCF7L2 risk genotype as described herein,in more particular whether he/she has one or more single nucleotidepolymorphisms (SNPs) in the gene coding for TCF7L2, especially at leastone SNP selected from rs7903146, rs12255372 and rs10885406, especiallyrs7903146, for example whether the subject carries at least one T alleleof SNP rs7903146 of TCF7L2, e.g. whether the subject is of CT genotype(i.e. whether the patient carries one T allele of SNP rs7903146 ofTCF7L2) or whether the subject is of TT genotype (i.e. whether thepatient carries two T alleles of SNP rs7903146 of TCF7L2), or testingwhether the subject is of TCF7L2 wild genotype, in particular whetherthe subject is of the TCF7L2 rs7903146 CC wild genotype; and thusdetermining the probability of likelihood of a favourable response (e.g.favorable change in HbA1c) resulting from therapeutic or preventivetreatment of the subject with the DPP-4 inhibitor, pharmaceuticalcomposition or combination; and

(ii) administering an effective amount of the DPP-4 inhibitor,pharmaceutical composition or combination to the subject, where saidsubject is determined to have a high probability of likelihood of afavorable response (e.g. favorable change in HbA1c) resulting fromtherapeutic or preventive treatment with the DPP-4 inhibitor,pharmaceutical composition or combination.

The present invention further provides a therapeutic and/or preventivemethod or use of this invention for application in a patient in needthereof, said method or use comprising the steps of

-   -   obtaining and assaying a nucleic acid sample from an individual        with type 2 diabetes mellitus,    -   determining the efficacy and/or, optionally, the probability of        the likelihood of a favorable response (e.g. in providing        glycemic control, such as favorable change in HbA1c) to a        treatment with a DPP-4 inhibitor, preferably linagliptin, or the        DPP-4 inhibitor in combination with one or more other active        substances (e.g. antidiabetics), comprising detecting either TT        or CT or CC allele genotype at rs7903146 of TCF7L2 gene in        patient's sample,        -   wherein the presence of the TT, CT or CC genotype is            indicative of the efficacy to the treatment, and/or,            optionally,        -   wherein the presence of the TT genotype is indicative of a            decreased likelihood of favorable response and/or presence            of the CC genotype is indicative of an increased likelihood            of favorable response to the treatment, and    -   administering a therapeutically effective amount of the DPP-4        inhibitor, preferably linagliptin, or the DPP-4 inhibitor in        combination with one or more other active substances (e.g.        antidiabetics) to the individual.

It can be further found that by using a pharmaceutical composition orcombination according to this invention, an improvement of the glycemiccontrol can be achieved even in those patients who have insufficientglycemic control in particular despite treatment with the second orthird antidiabetic agent or a combination of the second with the thirdantidiabetic agent, for example despite maximal tolerated dose of oralmonotherapy with metformin, a thiazolidinedione (e.g. pioglitazone) or asulfonylurea, or a combination of metformin with a thiazolidinedione(e.g. pioglitazone), of metformin with a sulfonylurea, or of athiazolidinedione (e.g. pioglitazone) with a sulfonylurea.

It can be also found that by using a combination according to thisinvention, an improvement of the glycemic control can be achieved evenin those patients who have insufficient glycemic control in particulardespite treatment with a DPP-4 inhibitor or a combination of a DPP-4inhibitor with the second or third antidiabetic agent, for exampledespite maximal tolerated dose of oral monotherapy with a DPP-4inhibitor or a dual combination of a DPP-4 inhibitor with the second orthird antidiabetic agent.

A maximal tolerated dose with regard to metformin is for example 2000 mgper day, 1500 mg per day (for example in asian countries) or 850 mgthree times a day or any equivalent thereof.

Therefore, the method and/or use according to this invention isapplicable in those patients who show one, two or more of the followingconditions:

-   -   (a) insufficient glycemic control with diet and exercise alone;    -   (b) insufficient glycemic control despite monotherapy with        metformin, a thiazolidinedione (e.g. pioglitazone), a        sulfonylurea, GLP-1 or GLP-1 analogue, or insulin or insulin        analogue, in particular despite oral monotherapy at a maximal        tolerated dose of metformin, a thiazolidinedione (e.g.        pioglitazone) or a sulfonylurea;    -   (c) insufficient glycemic control despite combination therapy        with two agents selected from the group consisting of metformin,        a thiazolidinedione (e.g. pioglitazone), a sulfonylurea, GLP-1        or GLP-1 analogue, and insulin or insulin analogue, for example        despite combination therapy with a dual combination selected        from metformin/pioglitazone, metformin/sulphonylurea,        metformin/insulin, sulphonylurea/pioglitazone,        sulphonylurea/insulin and pioglitazone/insulin;

The dual or triple combination method and/or use according to thisinvention is further applicable in those patients who show the followingconditions (e) or (f), respectively:

-   -   (d) insufficient glycemic control despite oral monotherapy with        the DPP-4 inhibitor, in particular despite oral monotherapy at a        maximal tolerated dose of the DPP-4 inhibitor;    -   (e) insufficient glycemic control despite (oral) combination        therapy with the DPP-4 inhibitor and the second or third        antidiabetic agent, in particular despite oral dual therapy at a        maximal tolerated dose of at least one of the combination        partners.

In an embodiment of this invention, a pharmaceutical composition orcombination is suitable in the treatment of patients who are diagnosedhaving one or more of the following conditions

-   -   insulin resistance,    -   hyperinsulinemia,    -   pre-diabetes,    -   type 2 diabetes mellitus, particular having a late stage type 2        diabetes mellitus,    -   type 1 diabetes mellitus.

Furthermore, a pharmaceutical composition or combination according tothis invention is particularly suitable in the treatment of patients whoare diagnosed having one or more of the following conditions

-   -   (a) obesity (including class I, II and/or III obesity), visceral        obesity and/or abdominal obesity,    -   (b) triglyceride blood level ≥150 mg/dL,    -   (c) HDL-cholesterol blood level <40 mg/dL in female patients and        <50 mg/dL in male patients,    -   (d) a systolic blood pressure ≥130 mm Hg and a diastolic blood        pressure ≥85 mm Hg,    -   (e) a fasting blood glucose level ≥110 mg/dL or ≥100 mg/dL.

It is assumed that patients diagnosed with impaired glucose tolerance(IGT), impaired fasting blood glucose (IFG), with insulin resistanceand/or with metabolic syndrome suffer from an increased risk ofdeveloping a cardiovascular disease, such as for example myocardialinfarction, coronary heart disease, heart insufficiency, thromboembolicevents. A glycemic control according to this invention may result in areduction of the cardiovascular risks.

Furthermore, the pharmaceutical composition and the methods according tothis invention are particularly suitable in the treatment of patientsafter organ transplantation, in particular those patients who arediagnosed having one or more of the following conditions

-   -   (a) a higher age, in particular above 50 years,    -   (b) male gender;    -   (c) overweight, obesity (including class I, II and/or III        obesity), visceral obesity and/or abdominal obesity,    -   (d) pre-transplant diabetes,    -   (e) immunosuppression therapy.

A pharmaceutical composition or combination according to this invention,in particular due to the DPP-4 inhibitor therein, exhibits a good safetyprofile. Therefore, a treatment or prophylaxis according to thisinvention is possible in those patients for which the mono-therapy withanother antidiabetic drug, such as for example metformin, iscontraindicated and/or who have an intolerance against such drugs attherapeutic doses. In particular, a treatment or prophylaxis accordingto this invention may be advantageously possible in those patientsshowing or having an increased risk for one or more of the followingdisorders: renal insufficiency or diseases, cardiac diseases, cardiacfailure, hepatic diseases, pulmonal diseases, catabolytic states and/ordanger of lactate acidosis, or female patients being pregnant or duringlactation.

Furthermore, it can be found that the administration of a pharmaceuticalcomposition or combination according to this invention results in norisk or in a low risk of hypoglycemia. Therefore, a treatment orprophylaxis according to this invention is also advantageously possiblein those patients showing or having an increased risk for hypoglycemia.

A pharmaceutical composition or combination according to this inventionis particularly suitable in the long term treatment or prophylaxis ofthe diseases and/or conditions as described hereinbefore andhereinafter, in particular in the long term glycemic control in patientswith type 2 diabetes mellitus.

The term “long term” as used hereinbefore and hereinafter indicates atreatment of or administration in a patient within a period of timelonger than 12 weeks, preferably longer than 25 weeks, even morepreferably longer than 1 year.

Therefore, a particular embodiment of the present invention provides amethod for therapy, preferably oral therapy, for improvement, especiallylong term improvement, of glycemic control in patients with type 2diabetes mellitus, especially in patients with late stage type 2diabetes mellitus, in particular in patients additionally diagnosed ofoverweight, obesity (including class I, class II and/or class IIIobesity), visceral obesity and/or abdominal obesity.

The effects mentioned above are observed both, when the DPP-4 inhibitorand the second and, optionally, third antidiabetic agent areadministered together, for example simultaneously in one single or twoor three separate formulations, and/or when they are administered inalternation, for example successively in two or three separateformulations.

Within this invention it is to be understood that combinations orcombined uses envisage the separate, sequential, simultaneous,concurrent, chronologically staggered or alternating administration ofthe components. It will be appreciated that the DPP-4 inhibitor and theother active substance(s) can be administered in a single dosage form oreach in separate dosage forms.

In this context, “combination” or “combined” within the meaning of thisinvention also includes, without being limited, fixed and non-fixedforms and uses.

It will be appreciated that the amount of the pharmaceutical compositionaccording to this invention to be administered to the patient andrequired for use in treatment or prophylaxis according to the presentinvention will vary with the route of administration, the nature andseverity of the condition for which treatment or prophylaxis isrequired, the age, weight and condition of the patient, concomitantmedication and will be ultimately at the discretion of the attendantphysician. In general, however, the DPP-4 inhibitor and, optionally, thesecond and/or third antidiabetic agent according to this invention areincluded in the pharmaceutical composition, combination or dosage formin an amount sufficient that by their administration the glycemiccontrol in the patient to be treated is improved.

In the following preferred ranges of the amount of the DPP-4 inhibitor,the second and/or third antidiabetic agent to be employed in thepharmaceutical composition and the methods and uses according to thisinvention are described. These ranges refer to the amounts to beadministered per day with respect to an adult patient, in particular toa human being, for example of approximately 70 kg body weight, and canbe adapted accordingly with regard to an administration 2, 3, 4 or moretimes daily and with regard to other routes of administration and withregard to the age of the patient. The ranges of the dosage and amountsare calculated for the inidividual active moiety. Advantageously, thecombination therapy of the present invention utilizes lower dosages ofthe individual DPP-4 inhibitor and/or of the individual second and/orthird antidiabetic agent used in monotherapy or used in conventionaltherapeutics, thus avoiding possible toxicity and adverse side effectsincurred when those agents are used as monotherapies.

Within the scope of the present invention, the pharmaceuticalcomposition or combination is preferably administered orally. Otherforms of administration are possible and described hereinafter.Preferably the one or more dosage forms comprising the DPP-4 inhibitorand/or the second and/or the third antidiabetic agent is oral or usuallywell known.

In general, the amount of the DPP-4 inhibitor in the combinations,combination methods or combined uses of this invention is preferably inthe range from 1/5 to 1/1 of the amount usually recommended for amonotherapy using said DPP-4 inhibitor.

A preferred dosage range of linagliptin when administered orally is 0.5mg to 10 mg per day, preferably 2.5 mg to 10 mg, most preferably 1 mg to5 mg per day. The preferred range of amounts in the pharmaceuticalcomposition is 0.5 to 10 mg, in particular 1 to 5 mg. Examples ofparticular dosage strengths are are 1, 2.5, 5 or 10 mg. The applicationof the active ingredient may occur up to three times a day, preferablyone or two times a day. Suitable formulations for linagliptin may bethose formulations disclosed in the application WO 2007/128724, thedisclosure of which is incorporated herein in its entirety.

Typical dosage strengths of the dual fixed dose combination (tablet) oflinagliptin/metformin IR (immediate release) are 2.5/500 mg, 2.5/850 mgand 2.5/1000 mg, which may be administered 1-3 times a day, particularlytwice a day.

Typical dosage strengths of the dual fixed dose combination (tablet) oflinagliptin/metformin XR (extended release) are 5/500 mg, 5/1000 mg and5/1500 mg, which may be administered 1-2 times a day, particularly oncea day, preferably to be taken in the evening with meal, or 2.5/500 mg,2.5/750 mg and 2.5/1000 mg, which may be administered 1-2 times a day,particularly once a day two tablets, preferably to be taken in theevening with meal.

A preferred dosage range of sitagliptin when administered orally is from10 to 200 mg, in particular 25 to 150 mg per day. A recommended dose ofsitagliptin is 100 mg calculated for the active moiety (free baseanhydrate) once daily or 50 mg twice daily. The preferred range ofamounts in the pharmaceutical composition is 10 to 150 mg, in particular25 to 100 mg. Examples are 25, 50, 75 or 100 mg. The application of theactive ingredient may occur up to three times a day, preferably one ortwo times a day. Equivalent amounts of salts of sitagliptin, inparticular of the phosphate monohydrate can be calculated accordingly.Adjusted dosages of sitagliptin, for example 25 and 50 mg, arepreferably used for patients with renal failure.

A preferred dosage range of vildagliptin when administered orally isfrom 10 to 150 mg daily, in particular from 25 to 150 mg, 25 and 100 mgor 25 and 50 mg or 50 and 100 mg daily. For example the dailyadministration of vildagliptin is 50 or 100 mg. The preferred range ofamounts in the pharmaceutical composition is 10 to 150 mg, in particular25 to 100 mg. Examples are 25, 50, 75 or 100 mg. The application of theactive ingredient may occur up to three times a day, preferably one ortwo times a day.

A preferred dosage range of alogliptin when administered orally is from5 to 250 mg daily, in particular from 10 to 150 mg daily. The preferredrange of amounts in the pharmaceutical composition is 5 to 150 mg, inparticular 10 to 100 mg. Examples are 10, 12.5, 20, 25, 50, 75 and 100mg. The application of the active ingredient may occur up to three timesa day, preferably one or two times a day.

A preferred dosage range of saxagliptin when administered orally is from2.5 to 100 mg daily, in particular from 2.5 to 50 mg daily. Thepreferred range of amounts in the pharmaceutical composition is from 2.5to 100 mg, in particular from 2.5 and 50 mg. Examples are 2.5, 5, 10,15, 20, 30, 40, 50 and 100 mg. The application of the active ingredientmay occur up to three times a day, preferably one or two times a day.

A preferred dosage range of dutogliptin when administered orally is from50 to 400 mg daily, in particular from 100 to 400 mg daily. Thepreferred range of amounts in the pharmaceutical composition is from 50to 400 mg. Examples are 50, 100, 200, 300 and 400 mg. The application ofthe active ingredient may occur up to three times a day, preferably oneor two times a day.

A special embodiment of the DPP-4 inhibitors of this invention refers tothose orally administered DPP-4 inhibitors which are therapeuticallyefficacious at low dose levels, e.g. at dose levels <100 mg or <70 mgper patient per day, preferably <50 mg, more preferably <30 mg or <20mg, even more preferably from 1 mg to 10 mg (if required, divided into 1to 4 single doses, particularly 1 or 2 single doses, which may be of thesame size), particularly from 1 mg to 5 mg (more particularly 5 mg), perpatient per day, preferentially, administered orally once-daily, morepreferentially, at any time of day, administered with or without food.Thus, for example, the daily oral amount 5 mg BI 1356 can be given in aonce daily dosing regimen (i.e. 5 mg BI 1356 once daily) or in a twicedaily dosing regimen (i.e. 2.5 mg BI 1356 twice daily), at any time ofday, with or without food.

In general, the amount of the the second and/or third antidiabetic agentin the combinations, combination methods and/or combined uses of thisinvention is preferably in the range from 1/5 to 1/1 of the amountusually recommended for a monotherapy using said antidiabetic agent.Using lower dosages of the individual second and/or third antidiabeticagent compared with monotherapy could avoid or minimize possibletoxicity and adverse side effects incurred when those agents are used asmonotherapies.

A preferred dosage range of metformin when administered orally is 250 to3000 mg, in particular 500 to 2000 mg per day. The preferred range ofamounts in the pharmaceutical composition is 250 to 1000, in particular500 to 1000 mg or 250 to 850 mg respectively. Examples are 500, 750, 850or 1000 mg. Preferably the administration of said amounts is once, twiceor three times daily. For example the amounts of 500, 750 and 850 mgpreferably require once-daily, twice-daily or three-times daily dosingand the amount of 1000 mg preferably requires once-daily or twice-dailydosing. Certain controlled or sustained release formulations allow aonce-daily dosing. Metformin can be administered for example in the formas marketed under the trademarks GLUCOPHAGE™, GLUCOPHAGE-D™ orGLUCOPHAGE-XR™.

A preferred dosage range of pioglitazone when administered orally is 5to 50 mg per day. The preferred range of amounts in the pharmaceuticalcomposition is 5 to 50 mg, 10 to 45 mg and 15 to 45 mg respectively.Examples are 15, 30 or 45 mg. Preferably the administration of saidamounts is once or twice daily, in particular once daily. Pioglitazonecan be administered in the form as it is marketed for example under thetrademark ACTOS™.

A preferred dosage range of rosiglitazone when administered orally is 1mg to 10 mg per day. The preferred range of amounts in thepharmaceutical composition is 1 to 10 mg, 2 to 8 mg, 4 to 8 mg and 1 to4 mg. Examples are 1, 2, 4 or 8 mg. Preferably the administration ofsaid amounts is once or twice daily. Preferably the dose should notexceed 8 mg daily. Rosiglitazone can be administered in the form as itis marketed for example under the trademark AVANDIA™.

A preferred dosage range of a thiazolidindione (other than pioglitazoneor rosiglitazone as described above) when administered orally is 2 to100 mg per day. The preferred range of amounts in the pharmaceuticalcomposition for an administration once, twice or three times daily is 2to 100, 1 to 50 and 1 to 33 mg respectively.

A preferred dosage range of glibenclamide when administered orally is0.5 to 15 mg, in particular 1 to 10 mg per day. The preferred range ofamounts in the pharmaceutical composition is 0.5 to 5 mg, in particular1 to 4 mg. Examples are 1.0, 1.75 and 3.5 mg. Preferably theadministration of said amounts is once, twice or three-times daily.Glibenclamide can be administered in the form as it is marketed forexample under the trademark EUGLUCON™.

A preferred dosage range of glimepiride when administered orally is 0.5to 10 mg, in particular 1 to 6 mg per day. The preferred range ofamounts in the pharmaceutical composition is 0.5 to 10 mg, in particular1 to 6 mg. Examples are 1, 2, 3, 4, and 6 mg. Preferably theadministration of said amounts is once, twice or three-times daily,preferably once daily. Glimepiride can be administered in the form as itis marketed for example under the trademark AMARYL™.

A preferred dosage range of gliquidone when administered orally is 5 to150 mg, in particular 15 to 120 mg per day. The preferred range ofamounts in the pharmaceutical composition is 5 to 120 mg, in particular5 to 30 mg. Examples are 10, 20, 30 mg. Preferably the administration ofsaid amounts is once, twice, three-times or four-times daily. Gliquidonecan be administered in the form as it is marketed for example under thetrademark GLURENORM™.

A preferred dosage range of glibornuride when administered orally is 5to 75 mg per day. The preferred range of amounts in the pharmaceuticalcomposition is 5 to 75 mg, in particular 10 to 50 mg. Preferably theadministration of said amounts is once, twice or three-times daily.

A preferred dosage range of gliclazide when administered orally is 20 to300 mg, in particular 40 to 240 mg per day. The preferred range ofamounts in the pharmaceutical composition is 20 to 240 mg, in particular20 to 80 mg. Examples are 20, 30, 40 and 50 mg. Preferably theadministration of said amounts is once, twice or three-times daily.

A preferred dosage range of glisoxepide when administered orally is 1 to20 mg, in particular 1 to 16 mg per day. The preferred range of amountsin the pharmaceutical composition is 1 to 8 mg, in particular 1 to 4 mg.Preferably the administration of said amounts is once, twice,three-times or four-times daily.

A preferred dosage range of tolbutamide when administered orally is 100to 3000 mg, preferably 500 to 2000 mg per day. The preferred range ofamounts in the pharmaceutical composition is 100 to 1000 mg. Preferablythe administration of said amounts is once or twice daily.

A preferred dosage range of glipizide when administered orally is 1 to50 mg, in particular 2.5 to 40 mg per day. The preferred range ofamounts in the pharmaceutical composition for an administration once,twice or three times daily is 1 to 50, 0.5 to 25 and 0.3 to 17 mgrespectively.

A preferred dosage range of nateglinide when administered orally is 30to 500 mg, in particular 60 to 360 mg per day. The preferred range ofamounts in the pharmaceutical composition is 30 to 120 mg. Examples are30, 60 and 120 mg. Preferably the administration of said amounts isonce, twice or three-times daily. Nateglinide can be administered in theform as it is marketed for example under the trademark STARLIX™.

A preferred dosage range of repaglinide when administered orally is 0.1to 16 mg, in particular 0.5 to 6 mg per day.

The preferred range of amounts in the pharmaceutical composition is 0.5to 4 mg. Examples are 0.5, 1, 2 or 4 mg. Preferably the administrationof said amounts is once, twice, three-times or four-times daily.Repaglinide can be administered in the form as it is marketed forexample under the trademark NOVONORM™.

A preferred dosage range of acarbose when administered orally is 50 to1000 mg, in particular 50 to 600 mg per day. The preferred range ofamounts in the pharmaceutical composition is 50 to 150 mg. Examples are50 and 100 mg. Preferably the administration of said amounts is once,twice, three-times or four-times daily. Acarbose can be administered inthe form as it is marketed for example under the trademark Glucobay™.

A preferred dosage range of voglibose when administered orally is 100 to1000 mg, in particular 200 to 600 mg per day. The preferred range ofamounts in the pharmaceutical composition is 50 to 300 mg. Examples are50, 100, 150, 200 and 300 mg. Preferably the administration of saidamounts is once, twice, three-times or four-times daily. Voglibose canbe administered in the form as it is marketed for example under thetrademark Basen™ or Voglisan™.

A preferred dosage range of miglitol when administered orally is 25 to500 mg, in particular 25 to 300 mg per day. The preferred range ofamounts in the pharmaceutical composition is 25 to 100 mg. Examples are25, 50 and 100 mg. Preferably the administration of said amounts isonce, twice, three-times or four-times daily. Miglitol can beadministered in the form as it is marketed for example under thetrademark Glyset™.

A preferred dosage range of GLP-1 analogues, in particular of exenatideis 5 to 30 μg, in particular 5 to 20 μg per day. The preferred range ofamounts in the pharmaceutical composition is 5 to 10 μg. Examples are 5and 10 μg. Preferably the administration of said amounts is once, twice,three-times or four-times daily by subcutaneous injection. Exenatide canbe administered in the form as it is marketed for example under thetrademark Byetta™. A long acting formulation, preferably for a onceweekly subcutaneous injection, comprises an amount from 0.1 to 3.0 mg,preferably 0.5 to 2.0 mg exenatide. Examples are 0.8 mg and 2.0 mg. Anexample of a long acting formulation of exenatide is Byetta LAR™.

A preferred dosage range of liraglutide is 0.5 to 3 mg, in particular0.5 to 2 mg per day. The preferred range of amounts in thepharmaceutical composition is 0.5 to 2 mg. Examples are 0.6, 1.2 and 1.8mg. Preferably the administration of said amounts is once or twice dailyby subcutaneous injection.

The amount of the DPP-4 inhibitor and the second and/or thirdtherapeutic agent in the pharmaceutical composition and in the methodsand uses of this invention correspond to the respective dosage ranges asprovided hereinbefore. For example, preferred dosage ranges in apharmaceutical composition, combination, method and use according tothis invention are an amount of 0.5 to 10 mg (in particular 1 to 5 mg,especially 2.5 mg or 5 mg) of linagliptin and/or, optionally, an amountof 250 to 1000 mg (especially 500 mg, 850 mg or 1000 mg) of metformin.An oral administration once or twice daily is preferred.

In the combination methods and combined uses according to the presentinvention the DPP-4 inhibitor and the second and/or third therapeuticagent are administered in combination including, without being limited,the active ingredients are administered at the same time, i.e.simultaneously, or essentially at the same time, or the activeingredients are administered in alternation, i.e. that at first one ortwo active ingredients are administered and after a period of time theother two or one active ingredients are administered, i.e. at least twoof the three active ingredients are administered sequentially. Theperiod of time may be in the range from 30 min to 12 hours. Theadministration which is in combination or in alternation may be once,twice, three times or four times daily, preferably once or twice daily.

With regard to combined administration of the DPP-4 inhibitor and thesecond and/or third antidiabetic agent, all three active ingredients maybe present in one single dosage form, for example in one tablet orcapsule, or one or two of the active ingredients may be present in aseparate dosage form, for example in two different or identical dosageforms.

With regard to their administration in alternation, one or two of theactive ingredients are present in a separate dosage form, for example intwo different or identical dosage forms.

Therefore, a pharmaceutical combination of this invention may be presentas single dosage forms which comprise the DPP-4 inhibitor and the secondand, optionally, the third antidiabetic agent. Alternatively apharmaceutical combination of this invention may be present as twoseparate dosage forms wherein one dosage form comprises the DPP-4inhibitor and the other dosage form comprises the second plus,optionally, the third antidiabetic agent, or, in case of a triplecombination, one dosage form comprises the DPP-4 inhibitor inhibitorplus either the second or the third antidiabetic agent and the otherdosage form comprises the third or the second antidiabetic agent,respectively. Alternatively, in case of a triple combination, apharmaceutical combination of this invention may be present as threeseparate dosage forms wherein one dosage form comprises the DPP-4inhibitor and a second dosage form comprises the second antidiabeticagent and the third dosage form comprises the third antidiabetic agent.Alternatively, in case of a dual combination, a pharmaceuticalcombination of this invention may be present as two separate dosageforms wherein one dosage form comprises the DPP-4 inhibitor and thesecond dosage form comprises the second antidiabetic agent.

The case may arise in which an active ingredient has to be administeredmore often, for example twice per day, than the other activeingredient(s), which for example needs administration once daily.Therefore “administration in combination” also includes anadministration scheme in which first all active ingredients areadministered in combination and after a period of time an activeingredient is administered again or vice versa.

Therefore, the present invention also includes pharmaceuticalcombinations which are present in separate dosage forms wherein onedosage form comprises the DPP-4 inhibitor and the second and,optionally, the third, therapeutic agent and the other dosage formcomprises the second and/or the third therapeutic agent only.

Thus, the present invention also includes pharmaceutical compositions orcombinations for separate, sequential, simultaneous, concurrent,alternate or chronologically staggered use of the active ingredients orcomponents.

A pharmaceutical composition which is present as a separate or multipledosage form, preferably as a kit of parts, is useful in combinationtherapy to flexibly suit the individual therapeutic needs of thepatient.

According to a first embodiment a kit of parts comprises

-   -   (a) a first containment containing a dosage form comprising the        DPP-4 inhibitor and at least one pharmaceutically acceptable        carrier, and    -   (b) a second containment containing a dosage form comprising the        second antidiabetic agent and at least one pharmaceutically        acceptable carrier, and, optionally,    -   (c) a third containment containing a dosage form comprising the        third antidiabetic agent and at least one pharmaceutically        acceptable carrier.

According to a second embodiment a kit of parts comprises

-   -   (a) a first containment containing a dosage form comprising the        DPP-4 inhibitor and the second or third antidiabetic agent and        at least one pharmaceutically acceptable carrier, and    -   (b) a second containment containing a dosage form comprising the        third or second antidiabetic agent, respectively, and at least        one pharmaceutically acceptable carrier.

According to a third embodiment a kit of parts comprises

-   -   (a) a first containment containing a dosage form comprising the        DPP-4 inhibitor and at least one pharmaceutically acceptable        carrier, and    -   (b) a second containment containing a dosage form comprising the        second and third antidiabetic agent and at least one        pharmaceutically acceptable carrier.

A further aspect of the present invention is a manufacture comprisingthe pharmaceutical combination being present as separate dosage formsaccording to the present invention and a label or package insertcomprising instructions that the separate dosage forms are to beadministered in combination.

According to a first embodiment a manufacture comprises (a) apharmaceutical composition comprising a DPP-4 inhibitor according to thepresent invention and (b) a label or package insert which comprisesinstructions that the medicament may or is to be administered, forexample in combination, with a medicament comprising a secondantidiabetic agent according to the present invention or with a fixed orfree combination (e.g. a medicament) comprising a second antidiabeticagent and a third antidiabetic agent according to the present invention.

According to a second embodiment a manufacture comprises (a) a secondantidiabetic agent according to the present invention and (b) a label orpackage insert which comprises instructions that the medicament may oris to be administered, for example in combination, with a medicamentcomprising a DPP-4 inhibitor according to the present invention or witha a fixed or free-combination (e.g. a medicament) comprising a DPP-4inhibitor and a third antidiabetic agent according to the presentinvention.

According to a third embodiment a manufacture comprises (a) apharmaceutical composition comprising a DPP-4 inhibitor and a secondantidiabetic agent according to the present invention and (b) a label orpackage insert which comprises instructions that the medicament may oris to be administered, for example in combination, with a medicamentcomprising a third antidiabetic agent according to the presentinvention.

The desired dose of the pharmaceutical composition according to thisinvention may conveniently be presented in a once daily or as divideddose administered at appropriate intervals, for example as two, three ormore doses per day.

The pharmaceutical composition may be formulated for oral, rectal,nasal, topical (including buccal and sublingual), transdermal, vaginalor parenteral (including intramuscular, sub-cutaneous and intravenous)administration in liquid or solid form or in a form suitable foradministration by inhalation or insufflation. Oral administration ispreferred. The formulations may, where appropriate, be convenientlypresented in discrete dosage units and may be prepared by any of themethods well known in the art of pharmacy. All methods include the stepof bringing into association the active ingredient with one or morepharmaceutically acceptable carriers, like liquid carriers or finelydivided solid carriers or both, and then, if necessary, shaping theproduct into the desired formulation.

The pharmaceutical composition may be formulated in the form of tablets,granules, fine granules, powders, capsules, caplets, soft capsules,pills, oral solutions, syrups, dry syrups, chewable tablets, troches,effervescent tablets, drops, suspension, fast dissolving tablets, oralfast-dispersing tablets, etc.

The pharmaceutical composition and the dosage forms preferably comprisesone or more pharmaceutical acceptable carriers. Preferred carriers mustbe “acceptable” in the sense of being compatible with the otheringredients of the formulation and not deleterious to the recipientthereof. Examples of pharmaceutically acceptable carriers are known tothe one skilled in the art.

Pharmaceutical compositions suitable for oral administration mayconveniently be presented as discrete units such as capsules, includingsoft gelatin capsules, cachets or tablets each containing apredetermined amount of the active ingredient; as a powder or granules;as a solution, a suspension or as an emulsion, for example as syrups,elixirs or self-emulsifying delivery systems (SEDDS). The activeingredients may also be presented as a bolus, electuary or paste.Tablets and capsules for oral administration may contain conventionalexcipients such as binding agents, fillers, lubricants, disintegrants,or wetting agents. The tablets may be coated according to methods wellknown in the art. Oral liquid preparations may be in the form of, forexample, aqueous or oily suspensions, solutions, emulsions, syrups orelixirs, or may be presented as a dry product for constitution withwater or other suitable vehicle before use. Such liquid preparations maycontain conventional additives such as suspending agents, emulsifyingagents, non-aqueous vehicles (which may include edible oils), orpreservatives.

The pharmaceutical composition according to the invention may also beformulated for parenteral administration (e.g. by injection, for examplebolus injection or continuous infusion) and may be presented in unitdose form in ampoules, pre-filled syringes, small volume infusion or inmulti-dose containers with an added preservative. The compositions maytake such forms as suspensions, solutions, or emulsions in oily oraqueous vehicles, and may contain formulatory agents such as suspending,stabilizing and/or dispersing agents. Alternatively, the activeingredients may be in powder form, obtained by aseptic isolation ofsterile solid or by lyophilisation from solution, for constitution witha suitable vehicle, e.g. sterile, pyrogen-free water, before use.

Pharmaceutical compositions suitable for rectal administration whereinthe carrier is a solid are most preferably presented as unit dosesuppositories. Suitable carriers include cocoa butter and othermaterials commonly used in the art, and the suppositories may beconveniently formed by admixture of the active compound(s) with thesoftened or melted carrier(s) followed by chilling and shaping inmoulds.

For pharmaceutical application in warm-blooded vertebrates, particularlyhumans, the compounds of this invention are usually used in dosages from0.001 to 100 mg/kg body weight, preferably at 0.1-15 mg/kg, in each case1 to 4 times a day. For this purpose, the compounds, optionally combinedwith other active substances, may be incorporated together with one ormore inert conventional carriers and/or diluents, e.g. with corn starch,lactose, glucose, microcrystalline cellulose, magnesium stearate,polyvinylpyrrolidone, citric acid, tartaric acid, water, water/ethanol,water/glycerol, water/sorbitol, water/polyethylene glycol, propyleneglycol, cetylstearyl alcohol, carboxymethylcellulose or fatty substancessuch as hard fat or suitable mixtures thereof into conventional galenicpreparations such as plain or coated tablets, capsules, powders,suspensions or suppositories.

The pharmaceutical compositions according to this invention comprisingthe DPP-4 inhibitors as defined herein are thus prepared by the skilledperson using pharmaceutically acceptable formulation excipients asdescribed in the art. Examples of such excipients include, without beingrestricted to diluents, binders, carriers, fillers, lubricants, flowpromoters, crystallisation retardants, disintegrants, solubilizers,colorants, pH regulators, surfactants and emulsifiers.

Examples of suitable diluents for compounds according to embodiment Ainclude cellulose powder, calcium hydrogen phosphate, erythritol, lowsubstituted hydroxypropyl cellulose, mannitol, pregelatinized starch orxylitol. Among those diluents mannitol, low substituted hydroxypropylcellulose and pregelatinized starch are to be emphasized.

Examples of suitable lubricants for compounds according to embodiment Ainclude talc, polyethyleneglycol, calcium behenate, calcium stearate,hydrogenated castor oil or magnesium stearate. Among those lubricantsmagnesium stearate is to be emphasized.

Examples of suitable binders for compounds according to embodiment Ainclude copovidone (copolymerisates of vinylpyrrolidon with othervinylderivates), hydroxypropyl methylcellulose (HPMC),hydroxypropylcellulose (HPC), polyvinylpyrrolidon (povidone),pregelatinized starch, or low-substituted hydroxypropylcellulose(L-HPC). Among those binders copovidone and pregelatinized starch are tobe emphasized.

Examples of suitable disintegrants for compounds according to embodimentA include corn starch or crospovidone. Among those disintegrants cornstarch is to be emphasized.

Suitable methods of preparing pharmaceutical formulations of the DPP-4inhibitors according to embodiment A of the invention are

-   -   direct tabletting of the active substance in powder mixtures        with suitable tabletting excipients;    -   granulation with suitable excipients and subsequent mixing with        suitable excipients and subsequent tabletting as well as film        coating; or    -   packing of powder mixtures or granules into capsules.

Suitable granulation methods are

-   -   wet granulation in the intensive mixer followed by fluidised bed        drying;    -   one-pot granulation;    -   fluidised bed granulation; or    -   dry granulation (e.g. by roller compaction) with suitable        excipients and subsequent tabletting or packing into capsules.

An exemplary composition of a DPP-4 inhibitor according to embodiment Aof the invention comprises the first diluent mannitol, pregelatinizedstarch as a second diluent with additional binder properties, the bindercopovidone, the disintegrant corn starch, and magnesium stearate aslubricant; wherein copovidone and/or corn starch may be optional.

For details on dosage forms, formulations and administration of DPP-4inhibitors of this invention, reference is made to scientific literatureand/or published patent documents, particularly to those cited herein.

The pharmaceutical compositions (or formulations) may be packaged in avariety of ways. Generally, an article for distribution includes acontainer that contains the pharmaceutical composition in an appropriateform. Tablets are typically packed in an appropriate primary package foreasy handling, distribution and storage and for assurance of properstability of the composition at prolonged contact with the environmentduring storage. Primary containers for tablets may be bottles or blisterpacks.

A suitable bottle, e.g. for a pharmaceutical composition or combinationcomprising a DPP-4 inhibitor according to embodiment A of the invention,may be made from glass or polymer (preferably polypropylene (PP) or highdensity polyethylene (HD-PE)) and sealed with a screw cap. The screw capmay be provided with a child resistant safety closure (e.g.press-and-twist closure) for preventing or hampering access to thecontents by children. If required (e.g. in regions with high humidity),by the additional use of a desiccant (such as e.g. bentonite clay,molecular sieves, or, preferably, silica gel) the shelf life of thepackaged composition can be prolonged.

A suitable blister pack, e.g. for a pharmaceutical composition orcombination comprising a DPP-4 inhibitor according to embodiment A ofthe invention, comprises or is formed of a top foil (which is breachableby the tablets) and a bottom part (which contains pockets for thetablets). The top foil may contain a metalic foil, particularly analuminium or aluminium alloy foil (e.g. having a thickness of 20 μm to45 μm, preferably 20 μm to 25 μm) that is coated with a heat-sealingpolymer layer on its inner side (sealing side). The bottom part maycontain a multi-layer polymer foil (such as e.g. poly(vinyl choride)(PVC) coated with poly(vinylidene choride) (PVDC); or a PVC foillaminated with poly(chlorotriflouroethylene) (PCTFE)) or a multi-layerpolymer-metal-polymer foil (such as e.g. a cold-formable laminatedPVC/aluminium/polyamide composition).

The article may further comprise a label or package insert, which referto instructions customarily included in commercial packages oftherapeutic products, that may contain information about theindications, usage, dosage, administration, contraindications and/orwarnings concerning the use of such therapeutic products. In oneembodiment, the label or package inserts indicates that the compositioncan be used for any of the purposes described herein.

The pharmaceutical compositions and methods according to this inventionshow advantageous effects in the treatment and prevention of thosediseases and conditions as described hereinbefore. The dual combinationsshow advantageous effects compared with monotherapy with an activeingredient. The triple combinations show advantageous effects comparedwith dual therapy with one or two of the three active ingredients.Advantageous effects may be seen for example with respect to efficacy,dosage strength, dosage frequency, pharmacodynamic properties,pharmacokinetic properties, fewer adverse effects, convenience,compliance, etc.

With respect to linagliptin, the methods of synthesis are known to theskilled person and as described in the literature, in particular asdescribed in WO 2002/068420, WO 2004/018468, or WO 2006/048427, thedisclosures of which are incorporated herein. Polymorphous crystalmodifications and formulations of particular DPP-4 inhibitors aredisclosed in WO 2007/128721 and WO 2007/128724, respectively, thedisclosures of which are incorporated herein in their entireties.Formulations of particular DPP-4 inhibitors with metformin or othercombination partners are described in WO 2009/121945, the disclosure ofwhich is incorporated herein in its entirety.

The methods of synthesis for the further DPP-4 inhibitors are describedin the scientific literature and/or in published patent documents,particularly in those cited hereinbefore.

The active ingredients, in particular the DPP-4 inhibitor and/or thesecond and/or the third antidiabetic agent, may be present in the formof a pharmaceutically acceptable salt. Pharmaceutically acceptable saltsinclude, without being restricted thereto, such as salts of inorganicacid like hydrochloric acid, sulfuric acid and phosphoric acid; salts oforganic carboxylic acid like oxalic acid, acetic acid, citric acid,malic acid, benzoic acid, maleic acid, fumaric acid, tartaric acid,succinic acid and glutamic acid and salts of organic sulfonic acid likemethanesulfonic acid and p-toluenesulfonic acid. The salts can be formedby combining the compound and an acid in the appropriate amount andratio in a solvent and decomposer. They can be also obtained by thecation or anion exchange from the form of other salts.

The active ingredients or a pharmaceutically acceptable salt thereof maybe present in the form of a solvate such as a hydrate or alcohol adduct.

As different metabolic functional disorders often occur simultaneously,it is quite often indicated to combine a number of different activeprinciples with one another. Thus, depending on the functional disordersdiagnosed, improved treatment outcomes may be obtained if a DPP-4inhibitor is combined with active substances customary for therespective disorders, such as e.g. one or more active substancesselected from among the other antidiabetic substances, especially activesubstances that lower the blood sugar level or the lipid level in theblood, raise the HDL level in the blood, lower blood pressure or areindicated in the treatment of atherosclerosis or obesity.

The DPP-4 inhibitors mentioned above—besides their use inmono-therapy—may also be used in conjunction with other activesubstances, by means of which improved treatment results can beobtained. Such a combined treatment may be given as a free combinationof the substances or in the form of a fixed combination, for example ina tablet or capsule. Pharmaceutical formulations of the combinationpartner needed for this may either be obtained commercially aspharmaceutical compositions or may be formulated by the skilled manusing conventional methods. The active substances which may be obtainedcommercially as pharmaceutical compositions are described in numerousplaces in the prior art, for example in the list of drugs that appearsannually, the “Rote Liste®” of the federal association of thepharmaceutical industry, or in the annually updated compilation ofmanufacturers' information on prescription drugs known as the“Physicians' Desk Reference”.

Examples of antidiabetic combination partners are metformin;sulphonylureas such as glibenclamide, tolbutamide, glimepiride,glipizide, gliquidon, glibornuride and gliclazide; nateglinide;repaglinide; thiazolidinediones such as rosiglitazone and pioglitazone;PPAR gamma modulators such as metaglidases; PPAR-gamma agonists such asrivoglitazone, mitoglitazone, INT-131 or balaglitazone; PPAR-gammaantagonists; PPAR-gamma/alpha modulators such as tesaglitazar,muraglitazar, aleglitazar, indeglitazar and KRP297;PPAR-gamma/alpha/delta modulators such as e.g. lobeglitazone;AMPK-activators such as AICAR; acetyl-CoA carboxylase (ACC1 and ACC2)inhibitors; diacylglycerol-acetyltransferase (DGAT) inhibitors;pancreatic beta cell GCRP agonists such as SMT3-receptor-agonists andGPR119, such as the GPR119 agonists5-ethyl-2-{4-[4-(4-tetrazol-1-yl-phenoxymethyl)-thiazol-2-yl]-piperidin-1-yl}-pyrimidineor5-[1-(3-isopropyl-[1,2,4]oxadiazol-5-yl)-piperidin-4-ylmethoxy]-2-(4-methanesulfonyl-phenyl)-pyridine;11B-HSD-inhibitors; FGF19 agonists or analogues; alpha-glucosidaseblockers such as acarbose, voglibose and miglitol; alpha2-antagonists;insulin and insulin analogues such as human insulin, insulin lispro,insulin glusilin, r-DNA-insulinaspart, NPH insulin, insulin detemir,insulin degludec, insulin tregopil, insulin zinc suspension and insulinglargin; Gastric inhibitory Peptide (GIP); amylin and amylin analogues(e.g. pramlintide or davalintide); GLP-1 and GLP-1 analogues such asExendin-4, e.g. exenatide, exenatide LAR, liraglutide, taspoglutide,lixisenatide (AVE-0010), LY-2428757, dulaglutide (LY-2189265),semaglutide or albiglutide; SGLT2-inhibitors such as e.g. dapagliflozin,sergliflozin (KGT-1251), atigliflozin, canagliflozin, ipragliflozin ortofogliflozin; inhibitors of protein tyrosine-phosphatase (e.g.trodusquemine); inhibitors of glucose-6-phosphatase;fructose-1,6-bisphosphatase modulators; glycogen phosphorylasemodulators; glucagon receptor antagonists;phosphoenolpyruvatecarboxykinase (PEPCK) inhibitors; pyruvatedehydrogenasekinase (PDK) inhibitors; inhibitors of tyrosine-kinases (50mg to 600 mg) such as PDGF-receptor-kinase (cf. EP-A-564409, WO98/35958, U.S. Pat. No. 5,093,330, WO 2004/005281, and WO 2006/041976)or of serine/threonine kinases; glucokinase/regulatory proteinmodulators incl. glucokinase activators; glycogen synthase kinaseinhibitors; inhibitors of the SH2-domain-containing inositol5-phosphatase type 2 (SHIP2); IKK inhibitors such as high-dosesalicylate; JNK1 inhibitors; protein kinase C-theta inhibitors; beta 3agonists such as ritobegron, YM 178, solabegron, talibegron, N-5984,GRC-1087, rafabegron, FMP825; aldosereductase inhibitors such as AS3201, zenarestat, fidarestat, epalrestat, ranirestat, NZ-314, CP-744809,and CT-112; SGLT-1 or SGLT-2 inhibitors, such as e.g. dapagliflozin,sergliflozin, atigliflozin, canagliflozin or(1S)-1,5-anhydro-1-[3-(1-benzothiophen-2-ylmethyl)-4-fluorophenyl]-D-glucitol;KV 1.3 channel inhibitors; GPR40 modulators such as e.g.[(35)-6-({2′,6′-dimethyl-4′-[3-(methylsulfonyl)propoxy]biphenyl-3-yl}methoxy)-2,3-dihydro-1-benzofuran-3-yl]aceticacid; SCD-1 inhibitors; CCR-2 antagonists; dopamine receptor agonists(bromocriptine mesylate [Cycloset]);4-(3-(2,6-dimethylbenzyloxy)phenyl)-4-oxobutanoic acid; sirtuinstimulants; and other DPP IV inhibitors.

Metformin is usually given in doses varying from about 500 mg to 2000 mgup to 2500 mg per day using various dosing regimens from about 100 mg to500 mg or 200 mg to 850 mg (1-3 times a day), or about 300 mg to 1000 mgonce or twice a day, or delayed-release metformin in doses of about 100mg to 1000 mg or preferably 500 mg to 1000 mg once or twice a day orabout 500 mg to 2000 mg once a day. Particular dosage strengths may be250, 500, 625, 750, 850 and 1000 mg of metformin hydrochloride.

For children 10 to 16 years of age, the recommended starting dose ofmetformin is 500 mg given once daily. If this dose fails to produceadequate results, the dose may be increased to 500 mg twice daily.Further increases may be made in increments of 500 mg weekly to amaximum daily dose of 2000 mg, given in divided doses (e.g. 2 or 3divided doses). Metformin may be administered with food to decreasenausea.

A dosage of pioglitazone is usually of about 1-10 mg, 15 mg, 30 mg, or45 mg once a day.

Rosiglitazone is usually given in doses from 4 to 8 mg once (or dividedtwice) a day (typical dosage strengths are 2, 4 and 8 mg).

Glibenclamide (glyburide) is usually given in doses from 2.5-5 to 20 mgonce (or divided twice) a day (typical dosage strengths are 1.25, 2.5and 5 mg), or micronized glibenclamide in doses from 0.75-3 to 12 mgonce (or divided twice) a day (typical dosage strengths are 1.5, 3, 4.5and 6 mg).

Glipizide is usually given in doses from 2.5 to 10-20 mg once (or up to40 mg divided twice) a day (typical dosage strengths are 5 and 10 mg),or extended-release glibenclamide in doses from 5 to 10 mg (up to 20 mg)once a day (typical dosage strengths are 2.5, 5 and 10 mg).

Glimepiride is usually given in doses from 1-2 to 4 mg (up to 8 mg) oncea day (typical dosage strengths are 1, 2 and 4 mg).

A dual combination of glibenclamide/metformin is usually given in dosesfrom 1.25/250 once daily to 10/1000 mg twice daily. (typical dosagestrengths are 1.25/250, 2.5/500 and 5/500 mg).

A dual combination of glipizide/metformin is usually given in doses from2.5/250 to 10/1000 mg twice daily (typical dosage strengths are 2.5/250,2.5/500 and 5/500 mg).

A dual combination of glimepiride/metformin is usually given in dosesfrom 1/250 to 4/1000 mg twice daily.

A dual combination of rosiglitazone/glimepiride is usually given indoses from 4/1 once or twice daily to 4/2 mg twice daily (typical dosagestrengths are 4/1, 4/2, 4/4, 8/2 and 8/4 mg).

A dual combination of pioglitazone/glimepiride is usually given in dosesfrom 30/2 to 30/4 mg once daily (typical dosage strengths are 30/4 and45/4 mg).

A dual combination of rosiglitazone/metformin is usually given in dosesfrom 1/500 to 4/1000 mg twice daily (typical dosage strengths are 1/500,2/500, 4/500, 2/1000 and 4/1000 mg).

A dual combination of pioglitazone/metformin is usually given in dosesfrom 15/500 once or twice daily to 15/850 mg thrice daily (typicaldosage strengths are 15/500 and 15/850 mg).

The non-sulphonylurea insulin secretagogue nateglinide is usually givenin doses from 60 to 120 mg with meals (up to 360 mg/day, typical dosagestrengths are 60 and 120 mg); repaglinide is usually given in doses from0.5 to 4 mg with meals (up to 16 mg/day, typical dosage strengths are0.5, 1 and 2 mg). A dual combination of repaglinide/metformin isavailable in dosage strengths of 1/500 and 2/850 mg.

Acarbose is usually given in doses from 25 to 100 mg with meals.Miglitol is usually given in doses from 25 to 100 mg with meals.

Examples of combination partners that lower the lipid level in the bloodare HMG-CoA-reductase inhibitors such as simvastatin, atorvastatin,lovastatin, fluvastatin, pravastatin, pitavastatin and rosuvastatin;fibrates such as bezafibrate, fenofibrate, clofibrate, gemfibrozil,etofibrate and etofyllinclofibrate; nicotinic acid and the derivativesthereof such as acipimox; PPAR-alpha agonists; PPAR-delta agonists;inhibitors of acyl-coenzyme

A:cholesterolacyltransferase (ACAT; EC 2.3.1.26) such as avasimibe;cholesterol resorption inhibitors such as ezetimib; substances that bindto bile acid, such as cholestyramine, colestipol and colesevelam;inhibitors of bile acid transport; HDL modulating active substances suchas D4F, reverse D4F, LXR modulating active substances and FXR modulatingactive substances; CETP inhibitors such as torcetrapib, JTT-705(dalcetrapib) or compound 12 from WO 2007/005572 (anacetrapib); LDLreceptor modulators; MTP inhibitors (e.g. lomitapide); and ApoB100antisense RNA.

A dosage of atorvastatin is usually from 1 mg to 40 mg or 10 mg to 80 mgonce a day.

Examples of combination partners that lower blood pressure arebeta-blockers such as atenolol, bisoprolol, celiprolol, metoprolol andcarvedilol; diuretics such as hydrochlorothiazide, chlortalidon,xipamide, furosemide, piretanide, torasemide, spironolactone,eplerenone, amiloride and triamterene; calcium channel blockers such asamlodipine, nifedipine, nitrendipine, nisoldipine, nicardipine,felodipine, lacidipine, lercanipidine, manidipine, isradipine,nilvadipine, verapamil, gallopamil and diltiazem; ACE inhibitors such asramipril, lisinopril, cilazapril, quinapril, captopril, enalapril,benazepril, perindopril, fosinopril and trandolapril; as well asangiotensin II receptor blockers (ARBs) such as telmisartan,candesartan, valsartan, losartan, irbesartan, olmesartan, azilsartan andeprosartan.

A dosage of telmisartan is usually from 20 mg to 320 mg or 40 mg to 160mg per day.

Examples of combination partners which increase the HDL level in theblood are Cholesteryl Ester Transfer Protein (CETP) inhibitors;inhibitors of endothelial lipase; regulators of ABC1; LXRalphaantagonists; LXRbeta agonists; PPAR-delta agonists; LXRalpha/betaregulators, and substances that increase the expression and/or plasmaconcentration of apolipoprotein A-I.

Examples of combination partners for the treatment of obesity aresibutramine; tetrahydrolipstatin (orlistat); alizyme (cetilistat);dexfenfluramine; axokine; cannabinoid receptor 1 antagonists such as theCB1 antagonist rimonobant; MCH-1 receptor antagonists; MC4 receptoragonists; NPY5 as well as NPY2 antagonists (e.g. velneperit); beta3-ARagonists such as SB-418790 and AD-9677; 5HT2c receptor agonists such asAPD 356 (lorcaserin); myostatin inhibitors; Acrp30 and adiponectin;steroyl CoA desaturase (SCD1) inhibitors; fatty acid synthase (FAS)inhibitors; CCK receptor agonists; Ghrelin receptor modulators; Pyy3-36; orexin receptor antagonists; and tesofensine; as well as the dualcombinations bupropion/naltrexone, bupropion/zonisamide,topiramate/phentermine and pramlintide/metreleptin.

Examples of combination partners for the treatment of atherosclerosisare phospholipase A2 inhibitors; inhibitors of tyrosine-kinases (50 mgto 600 mg) such as PDGF-receptor-kinase (cf. EP-A-564409, WO 98/35958,U.S. Pat. No. 5,093,330, WO 2004/005281, and WO 2006/041976); oxLDLantibodies and oxLDL vaccines; apoA-1 Milano; ASA; and VCAM-1inhibitors.

The present invention is not to be limited in scope by the specificembodiments described herein. Various modifications of the invention inaddition to those described herein may become apparent to those skilledin the art from the present disclosure. Such modifications are intendedto fall within the scope of the appended claims.

All patent applications cited herein are hereby incorporated byreference in their entireties.

Further embodiments, features and advantages of the present inventionmay become apparent from the following examples. The following examplesserve to illustrate, by way of example, the principles of the inventionwithout restricting it.

EXAMPLES Example 1 BI 1356, a Potent and Selective DPP-4 Inhibitor, isSafe and Efficacious in Patients With Inadequately Controlled Type 2Diabetes Despite Metformin Therapy

Efficacy and safety of BI 1356 (1, 5, or 10 mg qd), a potent andselective dipeptidyl peptidase-4 (DPP-4) inhibitor, was examined ininadequately controlled, metformin-treated (MET, g daily) type 2diabetic patients (T2DM; HbA1c at baseline 7.5-10.0%). Effects werecompared to add-on of placebo (PBO) or of open label glimepiride (GLIM;1 to 3 mg qd) in a 12-week randomized, double-blind study. Antidiabeticmedication other than metformin was washed out for 6 weeks (34.7% of thepatients).

The primary endpoint was change from baseline in HbA1c, adjusted forprior antidiabetic medication. 333 patients (mean baseline HbA1c 8.3%;fasting plasma glucose [FPG] 185 mg/dL) were randomized to BI 1356, PBOor open-label GLIM. After 12 weeks, BI 1356 treatment resulted insignificant placebo corrected mean reductions in HbA1c (BI 1356 1 mg,n=65, −0.39%; 5 mg, n=66, −0.75%; 10 mg, n=66, −0.73%). Patientsreceiving GLIM demonstrated a slightly greater mean PBO correctedreduction in HbA1c at Week 12 (n=64, −0.90%). Reductions in FPG frombaseline to Week 12 with BI 1356 were statistically significant (1 mg,−19 mg/dL; 5 mg, −35 mg/dL; 10 mg, −30 mg/dL). Hence, a dose-responserelationship was demonstrated for HbA1c and FPG, reaching an effectplateau at 5 mg of BI 1356. For this dose, >80% DPP-4 inhibition attrough in >80% of the patients at week 12 was achieved.

In total, 106 patients (43.1%) experienced adverse events (AEs) withsimilar incidences across all treatments. Most frequently reportedepisodes were nasopharyngitis (7.5%), diarrhoea (3.3%), and nausea(3.0%). Drug-related hypoglycaemia did not occur with BI 1356 or PBO butin 3 patients receiving GLIM. Ten patients (3.7%) experienced seriousAEs but none of these events were considered drug-related.

The addition of BI 1356 to MET in patients with T2DM inadequatelycontrolled on MET alone achieved clinically relevant and statisticallysignificant reductions in HbA1c. Combination treatment with BI 1356 1,5, and 10 mg and MET was well tolerated and no case of hypoglycaemia wasreported. The incidence of AEs was comparable with BI 1356 and PBO.

Example 2

The usability of a DPP-4 inhibitor or combination according to thisinvention for the purpose of the present invention (e.g. the beneficialeffect on glycemic control) can be tested using clinical trials.

For example, in a randomised, double-blind, placebo-controlled, parallelgroup trial, the safety and efficacy of a DPP-4 inhibitor according tothe invention (e.g. 5 mg of linagliptin administered orally once daily)is tested in patients with type 2 diabetes with insufficient glycemiccontrol (HbA1c from 7.0% to 10% or from 7.5% to 10% or from 7.5% to 11%)despite a therapy with one or two conventional antihyperglycemic agents,e.g. selected from metformin, thiazolidindiones (e.g. pioglitazone),sulfonylureas, glinides, inhibitors of alpha-glucosidase, GLP-1 or GLP-1analogues, and insulin or insulin analogues.

In the study with the sulphonylurea drug the efficacy and safety of aDPP-4 inhibitor according to this invention versus placebo added to abackground therapy of a sulphonylurea is investigated (2 week placeborun-in phase; 18 weeks double-blind treatment followed by 1 week followup after study medication termination; background therapy with asulphonylurea drug is administered throughout the entire trial duration,including placebo run-in phase, in an unchanged dosage).

The success of the treatment is tested by determining the HbA1c value,by comparison with the initial value and/or with the value of theplacebo group. A significant change in the HbA1c value compared with theinitial value and/or the placebo value demonstrates the efficacy of theDPP-4 inhibitor for the treatment. The success of the treatment can bealso tested by determining the fasting plasma glucose values, bycomparison with the initial values and/or with the values of the placebogroup. A significant drop in the fasting glucose levels demonstrates theefficacy of the treatment. Also, the occurrence of a treat to targetresponse (i.e. an HbA1c under treatment <7%) demonstrates the efficacyof the treatment.

The safety and tolerability of the treatment is investigated byassessing patient's condition and relevant changes from baseline, e.g.incidence and intensity of adverse events (such as e.g. hypoglycaemicepisodes or the like) or weight gain.

Example 3 Treatment of Pre-Diabetes

The efficacy of a pharmaceutical composition or combination according tothe invention in the treatment of pre-diabetes characterised bypathological fasting glucose and/or impaired glucose tolerance can betested using clinical studies. In studies over a shorter period (e.g.2-4 weeks) the success of the treatment is examined by determining thefasting glucose values and/or the glucose values after a meal or after aloading test (oral glucose tolerance test or food tolerance test after adefined meal) after the end of the period of therapy for the study andcomparing them with the values before the start of the study and/or withthose of a placebo group. In addition, the fructosamine value can bedetermined before and after therapy and compared with the initial valueand/or the placebo value. A significant drop in the fasting ornon-fasting glucose levels demonstrates the efficacy of the treatment.In studies over a longer period (12 weeks or more) the success of thetreatment is tested by determining the HbA1c value, by comparison withthe initial value and/or with the value of the placebo group. Asignificant change in the HbA1c value compared with the initial valueand/or the placebo value demonstrates the efficacy of the DPP-4inhibitors or combinations according to the present invention fortreating pre-diabetes.

Example 4 Preventing Manifest Type 2 Diabetes

Treating patients with pathological fasting glucose and/or impairedglucose tolerance (pre-diabetes) is also in pursuit of the goal ofpreventing the transition to manifest type 2 diabetes. The efficacy of atreatment can be investigated in a comparative clinical study in whichpre-diabetes patients are treated over a lengthy period (e.g. 1-5 years)with either a pharmaceutical composition or combination according tothis invention or with placebo or with a non-drug therapy or othermedicaments. During and at the end of the therapy, by determining thefasting glucose and/or a loading test (e.g. oGTT), a check is made todetermine how many patients exhibit manifest type 2 diabetes, i.e. afasting glucose level of >125 mg/dl and/or a 2 h value according to oGTTof >199 mg/dl. A significant reduction in the number of patients whoexhibit manifest type 2 diabetes when treated with a DPP-4 inhibitor orcombination according to the present invention as compared to one of theother forms of treatment, demonstrates the efficacy in preventing atransition from pre-diabetes to manifest diabetes.

Example 5 Treatment of Type 2 Diabetes

Treating patients with type 2 diabetes with the pharmaceuticalcomposition or combination according to the invention, in addition toproducing an acute improvement in the glucose metabolic situation,prevents a deterioration in the metabolic situation in the long term.This can be observed is patients are treated for a longer period, e.g. 3months to 1 year or even 1 to 6 years, with the pharmaceuticalcomposition or combination according to the invention and are comparedwith patients who have been treated with other antidiabetic medicaments.There is evidence of therapeutic success compared with patients treatedwith other antidiabetic medicaments if no or only a slight increase inthe fasting glucose and/or HbA1c value is observed. Further evidence oftherapeutic success is obtained if a significantly smaller percentage ofthe patients treated with a pharmaceutical composition or combinationaccording to the invention, compared with patients who have been treatedwith other medicaments, undergo a deterioration in the glucose metabolicposition (e.g. an increase in the HbA1c value to >6.5% or >7%) to thepoint where treatment with an additional oral antidiabetic medicament orwith insulin or with an insulin analogue is indicated.

Example 6 Treatment of Insulin Resistance

In clinical studies running for different lengths of time (e.g. 2 weeksto 12 months) the success of the treatment is checked using ahyperinsulinaemic euglycaemic glucose clamp study. A significant rise inthe glucose infusion rate at the end of the study, compared with theinitial value or compared with a placebo group, or a group given adifferent therapy, proves the efficacy of a DPP-4 inhibitor,pharmaceutical composition or combination according to the presentinvention according to the invention in the treatment of insulinresistance.

Example 7 Treatment of Hyperglycaemia

In clinical studies running for different lengths of time (e.g. 1 day to24 months) the success of the treatment in patients with hyperglycaemiais checked by determining the fasting glucose or non-fasting glucose(e.g. after a meal or a loading test with oGTT or a defined meal). Asignificant fall in these glucose values during or at the end of thestudy, compared with the initial value or compared with a placebo group,or a group given a different therapy, proves the efficacy of a DPP-4inhibitor, pharmaceutical composition or combination according to thepresent invention according to the invention in the treatment ofhyperglycaemia.

Example 8 Prevention of Micro- or Macrovascular Complications

The treatment of type 2 diabetes or pre-diabetes patients with a DPP-4inhibitor, pharmaceutical composition or combination according to theinvention prevents or reduces or reduces the risk of developingmicrovascular complications (e.g. diabetic neuropathy, diabeticretinopathy, diabetic nephropathy, diabetic foot, diabetic ulcer) ormacrovascular complications (e.g. myocardial infarct, acute coronarysyndrome, unstable angina pectoris, stable angina pectoris, stroke,peripheral arterial occlusive disease, cardiomyopathy, heart failure,heart rhythm disorders, vascular restenosis). Type 2 diabetes orpatients with pre-diabetes are treated long-term, e.g. for 1-6 years,with a pharmaceutical composition or combination according to theinvention and compared with patients who have been treated with otherantidiabetic medicaments or with placebo. Evidence of the therapeuticsuccess compared with patients who have been treated with otherantidiabetic medicaments or with placebo can be found in the smallernumber of single or multiple complications. In the case of macrovascularevents, diabetic foot and/or diabetic ulcer, the numbers are counted byanamnesis and various test methods. In the case of diabetic retinopathythe success of the treatment is determined by computer-controlledillumination and evaluation of the background to the eye or otherophthalmic methods. In the case of diabetic neuropathy, in addition toanamnesis and clinical examination, the nerve conduction rate can bemeasured using a calibrated tuning fork, for example. With regard todiabetic nephropathy the following parameters may be investigated beforethe start, during and at the end of the study: secretion of albumin,creatinine clearance, serum creatinin values, time taken for the serumcreatinine values to double, time taken until dialysis becomesnecessary.

Example 9 Treatment of Metabolic Syndrome

The efficacy of a DPP-4 inhibitor, pharmaceutical composition orcombination according to the present invention according to theinvention can be tested in clinical studies with varying run times (e.g.12 weeks to 6 years) by determining the fasting glucose or non-fastingglucose (e.g. after a meal or a loading test with oGTT or a definedmeal) or the HbA1c value. A significant fall in these glucose values orHbA1c values during or at the end of the study, compared with theinitial value or compared with a placebo group, or a group given adifferent therapy, proves the efficacy of an active substance orcombination of active substances in the treatment of Metabolic Syndrome.Examples of this are a reduction in systolic and/or diastolic bloodpressure, a lowering of the plasma triglycerides, a reduction in totalor LDL cholesterol, an increase in HDL cholesterol or a reduction inweight, either compared with the starting value at the beginning of thestudy or in comparison with a group of patients treated with placebo ora different therapy.

Example 10 Therapeutic Response to DPP-4 Inhibitor Treatment

Genomic DNA samples from individual patients enrolled in a clinicaltrial (e.g. a clinical study as described herein) for a DPP-4 inhibitor(e.g. linagliptin, e.g. in a daily oral amount of 5 mg, optionally incombination with one or more other antidiabetic agents) are obtained andgenotyped for variation(s) (e.g. polymorphisms) in one or more candidategenes selected from TCF7L2, KCNJ11, PPARG and GLP1 R, particularly for aTCF7L2 risk genotype as described herein, and evaluated relative to eachpatients response in the clinical trial (cf., e.g., Example 21). Theassociation between the likelihood (e.g., increased, decreased, or nolikelihood) of a favorable DPP-4 inhibitor therapy response (e.g.favorable change in HbA1c value) and genetic variations (e.g. TCF7L2risk genotypes) or references can be investigated by applyingstatistical analysis to the results of genotyping.

The probablility of the likelihood of a favorable response of anindividual resulting from treating said individual with the DPP-4inhibitor may be thus determined by such genotyping a nucleic acidsample of the individual, for example by detecting one or more singlenucleotide polymorphisms within the TCF7L2 gene, for example one SNPselected from rs7903146, rs12255372 and rs10885406, or by detecting therespective wild-type genotype (cf., e.g., Example 21).

Methods for genotyping, i.e. determining genetic variations (e.g.polymorphisms, particularly those described herein) from patients'nucleic acid samples are known in the art. For example, moleculargenetic methods to detect single nucleotide polymorphisms, e.g. withinthe TCF7L2 gene, may be based on genetic sequencing, microarray or PCRanalysis.

Example 11 Linagliptin Monotherapy Improves Glycemic Control andMeasures of β-Cell Function in Type 2 Diabetes

In a multi-center, 24 week, randomized, double-blind,placebo-controlled, parallel group study, the effects of linagliptin(LI) monotherapy (5 mg qd) are compared with placebo (PBO) in drug naïveor previously treated patients (pts) with type 2 diabetes mellitus(T2DM) (baseline HbA1c 4.9-10.6%). Randomization to LI (n=336) or PBO(n=167) follows a 2-week PBO run-in (previously treated pts go withoutmedication for 4 wks prior to this). Mean baseline demographics (HbA1c,8.0% [SD 0.87]; fasting plasma glucose (FPG), 166.0 mg/dL [41.1]; bodymass index (BMI), 29.05 kg/m2 [4.81]; age, 55.7 yrs [10.2]) are similarin both groups. The primary endpoint is the change from baseline inHbA1c after 24 wks of treatment. LI shows a PBO-adjusted change in HbA1cfrom baseline of −0.69% (p<0.0001) with a continuous HbA1c reductionover time of −0.46% at 6 weeks to −0.69% at 24 weeks (both p<0.0001). LIpatients are >4-fold more likely to achieve a reduction in HbA1c of≥0.5% at 24 weeks than PBO (47.1% vs 19.0%; p<0.0001). For patients withbaseline HbA1c ≥7.0% a significant greater number of LI-treated comparedto PBO-treated patients achieve a target reduction of HbA1c to <7.0% at24 weeks (25.2% vs. 11.6%; odds ratio of 2.9, p=0.0006). Patients withbaseline HbA1c levels of ≥9.0% show the greatest reduction in HbA1c(−0.86%) from baseline. FPG improves by −23.3 mg/dL (p<0.0001) vs. PBO.In a meal tolerance test, the LI patiens show a greater reduction in theadjusted mean change from baseline at week 24 for 2-hr postprandialglucose (PPG) (−58.4 mg/dL; p<0.0001) vs. PBO. LI improves insulinsecretion (p<0.05), as shown by changes in HOMA-% B index (LI, 5.02 vsPBO, −17.2 [(mU/L)/(mmol/L)]), proinsulin/insulin ratio (LI, −0.015 vsPBO, 0.024) and the disposition index (LI, 3.05 vs PBO, −0.68). Theproportion of patients reporting at least one adverse event (AE) issimilar for both groups (52.4% LI; 58.7% PBO). Hypoglycemia is rare,occurring in 1 patients in each of the groups. Serious AEs are reportedin both groups (LI, 3.0%; PBO, 4.2%) but are not considereddrug-related. Linagliptin trough levels in patients with mild andmoderate renal impairment are comparable to patients with normal renalfunction. Conclusion: Linagliptin monotherapy shows a significant,clinically meaningful and sustained improvement in glycemic controlreflected in changes in FPG and HbA1c, and accompanied by β-cellfunction improvements. Linagliptin is safe and well tolerated with noclinically significant changes in body weight or waist circumference.Linagliptin trough levels in patients with mild and moderate renalimpairment are comparable to patients with normal renal function,supporting that no dose adjustment is required in renally impairedpatients.

Example 12 Efficacy and Safety of Linagliptin in Type 2 DiabetesInadequately Controlled on Metformin Monotherapy

A multi-center, 24-week, randomized, placebo-controlled, double-blind,parallel group study examines the efficacy and safety of linagliptin(LI) administered as add-on therapy to metformin (MET) in type 2diabetes mellitus (T2DM) hyperglycemic patients with insufficientglycemic control (HbA1c to 0.0% for patients previously treated onlywith metformin, or ≥6.5 to ≥9.0% for patients previously treated withadditional oral antihyperglycemic drugs). Subjects who enter thescreening period discontinue previous antidiabetic medication other thanMET (≥1500 mg/day) for 6 weeks (including a placebo (PBO) run-in periodduring the last 2 weeks) prior to randomization to LI (n=524) or PBO(n=177). Mean baseline characteristics and demographics (HbA1c, 8.1%;fasting plasma glucose [FPG], 168.8 mg/dL; age, 56.5 yrs; BMI, 29.9kg/m2) are similar between groups. The primary endpoint is the changefrom baseline HbA1c after 24 weeks of treatment, evaluated with ananalysis of covariance (ANCOVA) adjusted for baseline HbA1c and priorantidiabetic medication. After 24 weeks of treatment, the adjusted meantreatment difference between LI+MET and PBO+MET is −0.64% (p<0.0001) infavor of LI+MET for change in HbA1c (%). Patients with a baseline HbA1cof ≥7.0% who receive LI+MET are more likely to achieve an HbA1c ≤7.0%relative to those receiving placebo+MET (26.2% vs. 9.2%, respectively;odds ratio, 4.4; p=0.0001). At week 24 LI+MET is superior to PBO+MET inreducing the mean fasting plasma glucose (FPG) from baseline (−21.1mg/dL; p<0.0001). At study-end, 2 hr post-prandial glucose (PPG)analyzed in meal tolerance tests shows a significantly greater(p<0.0001) mean reduction from baseline for the LI+MET treated (−67.1mg/dL) versus the PBO+MET group. The proportion of patients reporting atleast one adverse event (AE) is comparable within the LI+MET and PBO+METgroups (52.8% and 55.4%, respectively). Hypoglycemia is rare, occurringin 5 PBO+MET patients (2.8%) and 3 LI+MET patients (0.6%), all episodesbeing of mild intensity. The change in the body weight from baseline to24 weeks is similar between the 2 treatment groups (−0.5 kg PBO+MET;−0.4 kg LI+MET).

Conclusion, linagliptin 5 mg qd as add-on therapy in patients with T2DMinadequately controlled on metformin is well tolerated and producessignificant and clinically meaningful improvements in glycemic control(reductions in HbA1c, FPG and 2 h PPG without weight gain). Linagliptinas add-on therapy to metformin in patients with T2DM and insufficientglycemic control is well tolerated with the incidence of adverse eventscomparable to placebo.

Example 13 Linagliptin Improves Glycemic Control in Type 2 DiabetesPatients Inadequately Controlled by Metformin and Sulfonylurea WithoutWeight Gain or Hypoglycemia

A multi-center, 24-week, randomized, double-blind, placebo-controlled,parallel group study examines the efficacy and safety of the DPP-4inhibitor linagliptin (LI; 5 mg qd) in type 2 diabetes (T2DM) patients(pts) with insufficient glycemic control (HbA1c 7.0-10.0%) on thecombination of metformin (MET) plus a sulfonylurea (SU). Effects of LIas add-on are compared with placebo (PBO). All pts have a 2-wk PBOrun-in before being randomized to LI+MET+SU (n=793) or PBO+MET+SU(n=265). Mean baseline characteristics are: HbA1c, 8.14% (SD 0.8);fasting plasma glucose (FPG), 160.1 mg/dL (36.6); age, 58.1 yrs (9.8);BMI, 28.3 kg/m2 (4.7). Most of the pts (73.3%) have T2DM for >5 yearsbefore enrollment. The primary endpoint is the change from baseline inHbA1c after 24 weeks of treatment, adjusted for baseline HbA1c. After 24weeks of treatment, the mean HbA1c for LI+MET+SU is −0.62% lower(p<0.0001) relative to PBO+MET+SU. The maximum mean HbA1c reduction withLI+MET+SU is seen at week 12 (−0.84%). Patients with baseline HbA1c≥7.0% are >5-fold more likely to achieve a target HbA1c of <7.0% whentreated with LI+MET+SU (29.2%) compared with PBO+MET+SU (8.1%, oddsratio 5.5, p<0.0001) at 24 weeks. For the change in FPG, a statisticallysignificant (p<0.0001) adjusted mean difference of −12.7 mg/dL isobserved between Li+MET+SU and BPBO+MET+SU from baseline at week 24.Measures relating to β-cell function (fasting plasma insulin and HOMA-%B) along with HOMA-IR are significantly (p≤0.05) improved with LI+MET+SUcompared with PBO+MET+SU. The proportion of patients that reported asevere adverse event (AE) is low for both LI+MET+SU and PBO+MET+SUgroups (2.4% vs. 1.5%, respectively). The most frequent AE reported morecommonly in the LI+MET+SU group than in the PBO+MET+SU group ishypoglycemia (22.7% vs. 14.8%, respectively). This is expected due tothe combination with SU. No significant changes in weight are noted foreither treatment group. Conclusion: Therapy with linagliptin added tothe combination of metformin and a sulfonylurea is efficacious and safein producing significant and clinically meaningful improvements inglycemic control in T2DM patients. Linagliptin may provide an additionaloption prior to insulin therapy in many patients for whom glycemia isinsufficiently controlled with metformin plus a sulfonylurea agent.Linagliptin is shown to have a favorable safety and tolerablilityprofile. However, when linagliptin is added on pre-existing sulfonylureatherapy, hypoglycemia may occur.

Example 14 Efficacy and Safety of Initial Combination Therapy WithLinagliptin and Pioglitazone in Patients With Inadequately ControlledType 2 Diabetes

A multi-center, 24-week, randomized, double-blind, placebo-controlled,parallel group study investigates the efficacy and safety of initialcombination therapy with the DPP-4 inhibitor linagliptin (LI) andpioglitazone (PIO). Patients (pts) with type 2 diabetes mellitus (T2DM)and insufficient glycemic control (HbA1c 7.5-11.0%) who are drug naïveor previously treated with any oral antihyperglycemic drug (OAD), arerandomized to receive 5 mg LI plus 30 mg PIO qd (n=259) or 30 mg PIOplus placebo (PBO) qd (n=130). Patients do not take any OAD for at least6 weeks before randomization. Mean baseline characteristics (HbA1c 8.6%;fasting plasma glucose [FPG] 190 mg/dL; age 57.5 yrs; BMI 29.0 kg/m2)are similar between the groups. The primary endpoint is the change frombaseline in HbA1c after 24 weeks of treatment, adjusted for baselineHbA1c and prior antidiabetic medication. After 24 weeks of treatment,the adjusted mean change in HbA1c for the patients in the LI+PIO group(full analysis set, last observation carried forward) is −1.06%(standard error (SE) ±0.06). The difference in the adjusted mean HbA1cfor the LI+PIO group compared with PBO+PIO is −0.51% (p<0.0001; 95%confidence interval (CI), −0.71, −0.30). Reductions in FPG are alsosignificantly greater for the LI+PIO group compared with PBO+PIO with atreatment difference of −14.2 mg/dL (p<0.0001; 95% confidence interval(CI), −21.1, −7.3) at 24 weeks. Patients in the LI+PIO group are morelikely to achieve a target HbA1c of <7% vs. those on PBO+PIO (42.9% vs.30.5%, respectively, odds ratio 2.1; p=0.0051), as well as a reductionin HbA1c of ≥0.5% (75% vs. 50.8%, respectively, odds ratio 3.8;p<0.001). The proportion of patients that experienced at least oneadverse event (AE) is similar for both LI+PIO and PBO+PIO groups (136,52.5% vs. 53.1%, respectively). Hypoglycemia is rare, occurring in 3patients (1.2%) in the LI+PIO group and none in the PBO+PIO group. Allhypoglycemic events are of mild intensity.

Conclusion: Initial combination therapy with linagliptin andpioglitazone shows significant and clinically meaningful improvements inFPG and HbA1c levels compared with PIO alone, along with a greaterimprovement in beta-cell function. Co-administration of linagliptin withpioglitazone is shown to be safe and well tolerated. Combination therapywith linagliptin and pioglitazone may provide an important synergisticinitial treatment option for T2DM patients with inadequate glycemiccontrol or those with renal impairment for whom metformin iscontraindicated.

Example 15 Linagliptin Monotherapy Improves Glycemic Control in JapanesePatients With Type 2 Diabetes Mellitus Over 12 Weeks

A multi-center, 12-week, randomized, double-blind, placebo-controlled,parallel group study investigates the efficacy and safety of the DPP-4inhibitor linagliptin (LI). Effects of LI monotherapy (5 mg qd and 10 mgqd) are compared to placebo (PBO) in drug naïve or previously treatedJapanese patients (pts) with type 2 diabetes mellitus (T2DM) (baselineHbA1c 7.0-10.0%, if drug naïve; 7.0-9.0%, if previously treated). Beforebeing randomized to LI 5 (n=159) or 10 mg (n=160), or PBO (n=80), allpatients have a 2-week PBO run-in (patients on an oral antihyperglycemicdrug have no medication for 2 weeks prior to run-in). Mean [SD] baselinecharacteristics and demographics (HbA1c, 8.0% [0.68]; fasting plasmaglucose (FPG), 163.5 mg/dL [32.4]; BMI, 24.97 kg/m2 [3.86]; age, 60.0yrs [9.7]) are similar in all groups. The primary endpoint is the changefrom baseline in HbA1c after 12 weeks. The differences of adjusted meanchanges from baseline in HbA1c at week 12 are −0.87% for LI 5 mg vs. PBO(p<0.0001) and −0.88% for LI 10 mg vs. PBO (p<0.0001). Proportions ofpatients achieving HbA1c <7.0% after 12 wks are 26.4% for LI 5 mg and35.7% for LI 10 mg vs. 10.0% for PBO. Proportions of patients whoseHbA1c levels lower by at least 0.5% are 57.2% with LI 5 mg, 59.9% withLI 10 mg, and 8.8% with PBO. Both LI 5 mg and 10 mg show statisticallysignificant difference compared with PBO (p<0.0001). FPG issignificantly improved with both LI 5 and 10 mg compared to PBO: after12 weeks, the differences of adjusted mean changes from baseline are−19.7 mg/dL for LI 5 mg vs. PBO (p<0.0001) and −20.4 mg/dL for LI 10 mgvs. PBO (p<0.0001). As indicated by changes in the proinsulin/insulinratio (LI 5 mg, p=0.0065; LI 10 mg, p=0.0004), LI also significantlyimproves insulin secretion. The proportion of patients experiencing atleast one adverse event (AE) is comparable among the three groups (56.0%LI 5 mg, 53.1% LI 10 mg and 56.3% PBO). Of those; 9.4%, 8.8% and 10.0%,respectively, are assessed as being drug-related. There are noinvestigator-defined hypoglycemic episodes. Body weight is unchangedwith both LI 5 mg and 10 mg, −0.39 and −0.06 kg, respectively, which isnot sigificantly different vs. PBO (−0.04 kg).

Conclusion: Linagliptin demonstrates a significant and clinicallymeaningful improvement in glycemic control, reflected in changes inHbA1c and FPG in Japanese patients with T2DM. Both linagliptin 5 and 10mg doses have similar efficacy in lowering HbA1c and are well toleratedwithin this population. 5 mg linagliptin is the therapeutic dose inJapanese patients, which is identical to the therapeutic dose inCaucasians.

Example 16 Linagliptin Provides Superior Glycemic Control Compared toVoglibose as Monotherapy in Japanese Patients With Type 2 Diabetes

A multi-center, 26-week, randomized, double-blind, active-controlled,parallel group Study compares the efficacy and safety of the DPP-4inhibitor linagliptin (LI) vs. the α-glucosidase inhibitor voglibose(VB) in drug naïve or previously treated Japanese patients (pts) withType 2 diabetes mellitus (T2DM) (baseline HbA1c 7.0-10.0% if drug naïve,7.0-9.0% if previously treated with an oral antihyperglycemic drug(OAD)).

Following a 2-week PBO run-in, patients are randomized to LI 5 (n=159)or 10 mg qd (n=160), or VB (0.2 mg tid; n=162). Any previous OADtreatment is stopped 2 weeks prior to run-in. Mean baseline [SD]characteristics and demographics (HbA1c, 8.01% [0.68]; fasting plasmaglucose (FPG), 163.5 mg/dL [32.4]; BMI, 24.97 kg/m2 [3.86]; age, 60.0yrs [9.7]) are similar across groups. The primary endpoint is the changefrom baseline in HbA1c after 26 weeks. The differences of adjusted meanchanges from baseline in HbA1c at week 26 are −0.32% for LI 5 mg vs. VB(p=0.0003) and −0.39% for LI 10 mg vs. VB (p<0.0001). Proportions ofpatients achieving HbA1c <7.0% after 26 weeks are 30.2% for LI 5 mg and34.4% for LI 10 mg vs. 22.2% for VB. Proportions of patients whose HbA1clevel lowered by ≥0.5% are 57.2% and 53.5% for LI 5 and 10 mg, vs. 37.7%for VB. FPG is significantly improved with both LI 5 and 10 mg comparedto VB: the differences of adjusted mean changes from baseline are −6.9mg/dL for LI 5 mg vs. VB (p=0.02) and −9.8 mg/dL for LI 10 mg vs. VB(p=0.0015). Both LI 5 mg and 10 mg show a significant decrease of HbA1cin patients previously treated with 1 OAD compared with VB (p=0.003 andp=0.0011, respectively). The occurrence of ≥1 adverse event (AE) iscomparable between groups (72.3% LI 5 mg, 77.5% LI 10 mg and 71.6% VB).Of the AEs, 11.3%, 10.6% and 18.5%, respectively, are assessed as drugrelated. Drug-related gatsrointstinal disorders are more common in theVB (14.2%) than LI (8.2% 5 mg; 8.1% 10 mg) groups.ln the VB group, 1hypoglycemic episode is reported vs. none in the LI groups.

Conclusion: Linagliptin monotherapy demonstrates greater efficacy thanVB for improving glycemic control in Japanese patients with T2DM. Bothlinagliptin 5 mg and linagliptin 10 mg have comparable efficacy and showstatistically significant decreases in HbA1c and FPG from baselinecompared with VB after 26 weeks. Linagliptin is well tolerated inJapanese patients with T2DM compared to VB, with less gastrointestinalAEs, and may provide a valuable addition to the therapies available tothis population. 5 mg linagliptin is the therapeutic dose in Japanesepatients, which is identical to the therapeutic dose in Caucasians.

Example 17 Linagliptin Restores β-Cell Function and Survival in HumanIsolated Islets

Studies in diabetic animal models show that dipeptidyl peptidase-4(DPP-4) inhibitors reverse hyperglycemia and increase β-cell mass. Here,the role of linagliptin, a DPP-4 inhibitor on human β-cell function isinvestigated: Human isolated islets are exposed to increased glucoseconcentrations (5.5-33.3 mM), 0.5 mM palmitic acid, the mixture of 2ng/mL IL-1β or 1,000 U/mL IFN-γ for 4 days or 50 μM H2O2 for 8 h. Isletsare pre-treated with 500 ng/mL Interleukin-1 Receptor Antagonist(IL-1Ra, which has been shown to restore β-cell function), 100 nMlinagliptin or solvent for 1 h before exposure to the diabetic stimuliand during the whole 4-day treatment period. At control conditions,islets secrete 3.8-fold more insulin at 16.7 mM than at 2.8 mM glucose.In contrast, stimulatory index is 1.9- and 2.4-fold decreased whenislets are exposed to 11.1 mM and 33.3 mM glucose (P<0.05). Exposure ofthe islets to palmitate, cytokine mixture or H2O2 resulted in a 2.1-,2.2- and 1.9-fold reduction of glucose stimulated insulin secretion(GSIS), respectively (P<0.05). Linagliptin significantly restores β-cellfunction at all conditions (1.9-, 2.5-, 3.3-, 1.9- and 3.7-fold increasein GSIS at 11.1 or 33.3 mM glucose, palmitic acid, cytokines or H2O2,P<0.05). IL-1Ra is similarly effective in restoring β-cell function atconditions of high glucose, palmitic acid and cytokines, but IL-1Rafails to restore β-cell function at oxidative stress conditions inducedby H2O2 treatment. Since loss of function is mediated by oxidativestress, the nitrotyrosine concentration is measured in islet lysates.Nitrotyrosine levels are highly elevated in human islets under alldiabetic conditions (13-, 14-, 6-, 14- and 8-fold increased at 11.1 or33.3 mM glucose, palmitic acid, cytokines or H2O2, P<0.05), while noelevated nitrotyrosine production is observed in islets treated withlinagliptin.

In summary, it is shown that the DPP-4 inhibitor linagliptin hascomparable protective effects on gluco-, lipo- and cytokinetoxicity asIL-1Ra and, in addition, could improve β-cell function under oxidativestress conditions and blocks apoptosis (induced by H2O2 treatment). Thestudy provides evidence of a direct protective effect of linagliptin onβ-cell survival and insulin secretion.

Example 18 Chronic Renal Disease Does Not Change the Pharmacokinetics ofLinagliptin But Increases Exposure of Sitagliptin and Alogliptin in Rats

Renal impairment is a frequent complication of T2DM. The effect ofchronic renal disease on the pharmacokinetics of dipeptidyl peptidase-4inhibitors (linagliptin, sitagliptin, alogliptin) in a rat model ofchronic renal insufficiency (5/6 nephrectomy, 5/6N) is investigated:Eight weeks after surgery rats are treated orally with inhibitors for 4days. 5/6N causes a highly significantly (P<0.001) decrease ofglomerular filtration rate measured by creatinin clearance (sham:2510±210 mL/24 h; 5/6N: 1665±104.3 mL/24 h) and increases cystatin Clevels (sham: 700±35.7 ng/mL; 5/6N: 1434±77.6 ng/mL). Tubular functionis significantly (P<0.001) impaired as evidenced by plasma neutrophilgelatinase-associated lipocalin (NGAL), (sham: 286±23 ng/ml; 5/6N:680±56.3 ng/ml) and β2 microglobulin (sham: 20.4±2.4 μg/mL; 5/6N:33.3±1.34 μg/mL). DPP-4 activity is comparable among groups.

Administration of linagliptin (0.5 and 7 μmol/kg) to 5/6N rats shows nosignificant change in AUC(0-∞): sham: 316±54.7 nmol*h/L; 5/6N: 257±21.54nmol*h/L; P=0.771 and sham: 1252±372 nmol*h/L; 5/6N: 748±74.5 nmol*h/L;P=0.284, respectively. In contrast, both sitagliptin and alogliptin (7μmol/kg) have significantly (P=0.0001 and P=0.039) higher (41% and 28%)AUC(0-∞): sitagliptin sham: 3690±103 nmol* h/L; 5/6N: 6238±423 nmol*h/Land alogliptin sham: 1772±225 nmol*h/L; 5/6N: 2445±166 nmol*h/L).Furthermore, no correlation of markers of tubular and glomerularfunctions with linagliptin AUC is observed. In contrast, sitagliptinsignificantly correlate with creatinin clearance (r2=0.374, P<0.05),cystatin C (r2=0.499, P<0.01), NGAL (r2=0.604, P<0.01) and β2microglobulin (r2=0.543, P<0.01). Alogliptin correlates lesssignificantly with cystatin C (r2=0.376, P<0.05) and β2 microglobulin(r2=0.391, P<0.05) but not with creatinin clearance and NGAL.

These results demonstrate that renal impairment does not affect thepharmacokinetics of linagliptin whereas it increases the exposure ofsitagliptin and alogliptin. Therefore, in contrast to sitagliptin andalogliptin, linagliptin may not have to be dose-adjusted in patientswith T2DM and renal impairment or diabetic nephopathy.

Further, linagliptin significantly inhibits mRNA expression ofprofibrotic factors, such as TGF-pβ1, T1MP-1 and collagen (Col3alpha1)in the heart of uremic rats, which factors are tissue fibrosis markersof cardiac fibrosis and are increased in uremic heart. Characteristiccardiomyopathy with intestinal expansion and fibrosis develops often inuremia. Thus, these antifibrotic properties of DPP-4 inhibitors may beused for the treatment of cardiac and renal injury, uremic heart,cardiac fibrosis and/or cardiomyopathy with intestinal expansion andfibrosis associated with uremia in patients with type 2 diabetes. Theantifibrotic action of linagliptin can be an additional benefit forpatients with chronic kidney and/or heart diseases that often accompanytype 2 diabetes.

Example 19 Linagliptin Improves Hepatic Steatosis in Rodent Models

Hepatic steatosis is a hallmark of patients with Type 2 diabetes andnon-alcoholic fatty liver disease (NAFLD). Linagliptin is a selectiveand non-renal excreted inhibitor of dipeptidyl peptidase-4 (DPP-4).

In a model of diet-induced obesity (D10, fed for 2 and 3 months), theeffect of 4 weeks therapy with linagliptin (3 and 30 mg/kg/day, n=10) isinvestigated. Liver lipid content is detected by magnetic resonancespectroscopy (MRS) in vivo and by analysis of liver triglycerides exvivo. Linagliptin inhibits DPP-4 activity significantly (P<0.001) by 67%to 80% and 79% to 89% (3 and 30 mg/kg/day, respectively) compared tocontrols. Blood glucose levels following an OGTT (AUC) are significantly(P<0.01) decreased ranging from 16% to 20% (3 mg/kg/day) and 20% to 26%(30 mg/kg/day). Likewise, liver fat content (MRS detection) issignificantly reduced. Changes in liver fat content are visible as earlyas 2 weeks on treatment. The correlation between liver lipid content asmeasured by MRS and hepatic triglyceride levels as measured ex vivo isr2=0.565 (P<0.0001). Furthermore, ob/ob mice are analyzed after 14 daysof linagliptin treatment (3 mg/kg/day or control) and blindedhistological scoring is performed (severity and grade of fat content,markers of inflammation). DPP-4 activity is inhibited by 80% and bloodglucose AUC reduction is 25% (P<0.05). The histological score revealsless hepatic steatosis and inflammation in the linagliptin group(2.2±0.13, n=9, P<0.01) versus control (3±0.18, n=10).

In conclusion, linagliptin significantly reduces liver fat content andhistological NAFLD in a high fat diet model. Linagliptin reverses livertriglyceride content and hepatic steatosis (with greater therapeuticimpact when hepatic steatosis is more pronounced). The reversal ofhepatic steatosis supports the use of linagliptin in patients with Type2 diabetes as well as liver-associated diseases (NAFLD).

Example 20 Linagliptin Functionally Counteracts a Dysregulation in DPP-4Expression in Diabetes-Impaired Wounds

Impaired wound healing is a major complication of diabetes mellitus. Thedipeptidyl peptidase-4 (DPP-4) inhibitor linagliptin improves woundhealing (as shown in ob/ob mice). The impact of linagliptin oninflammatory markers in wounded skin is examined and a rationale for thebeneficial action of linagliptin on wound healing is provided:

Wounds of linagliptin (3 mg/kg/day) and mock-treated ob/ob mice for theinflammatory markers COX-2 and MIP by RNase protection assays areinvestigated with no significant differences. Furthermore, linagliptindoes not increase the number of apoptotic infiltrating F4/80-positivemacrophages. Therefore, the expression of DPP-4 in the skin of diabeticand non-diabetic animals is assessed. Immunohisto-chemistry (IHC) andimmunoblots reveal a strong expression of DPP-4 in skin from healthy anddiabetic (ob/ob) mice and keratinocytes as the major cellular source ofthe enzyme. In line, the localization of DPP-4 protein in the skinnicely correlates with whole body autoradiography obtained after[3H]-labelled linagliptin treatment. Analyzing DPP-4 expression in miceupon full-thickness excisional wounding it is found that in healthymice, DPP-4 protein expression declines over 3 days after injury and theenzyme remains absent in the late phase of repair. Interestingly, skininjury leads to a strong down-regulation of DPP-4 expression inproliferating wound margin keratinocytes (IHC). In contrast, in acutewounds of diabetic mice any DPP-4 expression can not be observed. DPP-4protein, however, is expressed in the late phase of wound repair. Theinverse regulation of DPP-4 protein in diabetic versus non-diabetic skinprovides a functional basis of the positive action of linagliptin inwound healing processes. Thus, improvement of the wound healing processmediated by a suitable DPP-4 inhibitor, such as linagliptin, depends onthe compensation (inhibition) of a dysregulated DPP-4 in diabetic woundsrather than on the anti-glycemic or immunomodulatory effects thereof.Thus, a DPP-4 inhibitor being suitable for improving wound healing issuch a DPP-4 inhibitor which can effectively bind to DPP-4 in the skin,e.g. to dysregulated DPP-4 in diabetic wounds, preferably in itstherapeutic dose level.

Furthermore in this context, a DPP-4 inhibitor being suitable forimproving wound healing, particularly in a type 2 diabetes patient, issuch a DPP-4 inhibitor which can be applied topically to wounds, e.g.comprised in wound dressings or patches or creams or ointments. Thus,the present invention further provides topical devices for wounds, suchas e.g. wound dressings or patches, comprising linagliptin and,optionally, one or more pharmaceutically acceptable carriers and/orexcipients.

Example 21 Association Study (Genotyping TCF7L2, Treatment Response)

The polymorphisms and variants of the gene TCF7L2 as depicted in theTable i can be analyzed as described in the following procedure:

TABLE i Gene, variant nucleotides and rs numbers. Gene variantnucleotide rs number TCF7L2 c.382-41435 C > T rs7903146 c.483 + 9017 G >T, rs12255372 c.382-22060 A > G rs10885406 c.1102 C > G rs731788

Samples

Patients' DNA samples (conc.: 50 ng/μl) in 96-well-plates are used forthe analytical methods applied.

Genotyping by Direct Sanger Sequencing

Using gDNA as a template, locus specific DNA fragments are amplified bypolymerase chain reaction (PCR).

PCR is carried out using an ABI BioRad® Tetrad PCR System. Quality ofthe PCR products is analyzed by agarose gel electrophoresis The purifiedPCR-products are used as templates in sequencing reactions According tothe chain terminating methodology of Sanger et al. (1977), the analysisof DNA sequence is based on the termination of a growing DNA strand dueto incorporation of a dye-labeled2′,3′-Dideoxyribonucleotidetriphosphate (ddNTP) by the DNA polymerase.Purified sequencing products are analyzed using an ABI PRISM® 3730Genetic Analyzer.

Sequencing data are generated using the original ABI Software. Thesubsequent KB-basecalling as well as the assembly is performed using theStaden Software Package. KB-basecalling assigns quality values to allcalled bases of automated sequencer traces using KB-basecaller errorprobabilities. These quality values are used during assembling thesingle reads and are the basic requirement for calculating the sequenceaccuracy (Applied Biosystems, 3730/3730xl/DNA Analyzer SequencingAnalysis Software Training).

A quality value (q) of 20 corresponds to an error probability (ep) of1/100, a value of 30 to an ep of 1/1000 and so on. In the assembly phasethose values are set against each other. In general sequencing iscontinued until each consensus base has a quality value (q) of 50 ormore. This corresponds to an error probability (ep) of 1/100000. Due tothe fact that most of the consensus bases have an even higher qualityscore than the minimal one, the calculated cumulative error probabilityfor the finished sequence is again significantly lower. Sequencing dataare uploaded and analyzed using the software seqpatient from jsi-medicalsystems (version Seq Pilot 3.3.2, JSI medical systems GmbH, Friedhofstr.5, 77971 Kippenheim, Germany).

Only traces that fulfill internal quality aspects are processed forfurther genotype analyses. Genotyping is carried out through theanalysis of single polymorphisms rather than the analysis of the entiregene. Therefore genotyping results refer only to the variant positionsdepicted in Table i.

Genotyping by TaqMan PCR

The TaqMan® technology comprises amplification of a PCR fragment withsimultaneous detection of the degradation of a labelled probe. Probesare labelled at both ends with an allele-specific dye and a quencher.During the amplification reaction, the specifically hybridized probe isdisplaced by the DNA polymerase. This displacement occurs either asdegradation through the 5′ exonuclease activity of the polymerase in thecase of a perfect match with the probe, or without degradation in thecase of a mismatch. Upon degradation, the quencher and dye are separatedand the fluorescence signal increased. An increase in the fluorescencesignal is indicative for the presence of the respective allele.Fluorescence signals are recorded with the ABI PRISM 7700 system(Applied Biosystems).

In detail, a master mix is prepared containing all components for PCRreaction and aliquoted in the appropriate number of wells. Subsequently,DNA is added to each well according to the plate layout; except forno-template control (NTC).

AB assay ID (rs7903146) C_29347861_10 SNP context sequence:(SEQ ID NO: 1) TAGAGAGCTAAGCACTTTTTAGATA[C/T]TATATAATTTAATTGCCG TATGAGG

The mastermix per sample contains:

Nuclease-free water 0.25 μl 2x PCR MasterMix  2.5 μl 20x Primer/ProbeMix 0.25 μl DNA [10 ng/μl]  2 μl In total:  5 μl

The cycling conditions are:

95° C. 10 min. 95° C. 15 sec. {close oversize brace} 50 cycles 60° C. 90sec.

The TaqMan® pre- and post-reads of the AD are performed on the TaqMan®7900HT Fast Real System. The SDS software V2.3 calculates thefluorescence measurements made during the plate read and plots Rn valuesbased on the signals from each well. Using the software, it isdetermined which SNP alleles are present in each sample. NTC should begiven as not determined.

Statistical Analyses

To assess the homogeneity of the treatment effect on the change frombaseline of HbA1c after 24 weeks in the genotype subgroups defined byTCF7L2 SNP rs7903146 genotypes an analysis of covariance (ANCOVA) modelincluding the treatment interaction with the covariate genotype isapplied for pooled data over four studies. The statistical modelincludes ‘Treatment’, ‘Genotype’, ‘Study’, ‘Wash-Out-Period for priororal antidiabetic drugs (yes/no)’, ‘Race’, as well as the interactionterm ‘Treatment*Genotype’ as fixed effects and ‘HbA1c baseline’ as alinear covariate. The ANCOVA model provides estimates for the meanchange from baseline in HbA1c after 24 weeks of therapy for thedifferent genotypes taking baseline clinical and demographic informationinto account.

Model based pair-wise comparisons between wild-type homozygous (genotypeCC) and heterozygous (genotype CT) or rare homozygous (genotype TT)individuals on linagliptin or combination treatment(linagliptin+pioglitazone, linagliptin+metformin,linagliptin+metformin+a sulphonylurea) are performed.

Additionally the results of the corresponding ANCOVA models without‘Genotype’ and ‘Treatment*Genotype’ fixed effects are given for thewhole patient population of the studies (full analysis set, FAS) as wellas for the subpopulation for which genetic analyses are performed (fullanalysis set for pharmacogenetic analyses, FASG) to demonstratecomparability of the observed effects.

The statistical evaluation is prepared using the software packages SASVersion 9.2 (SAS Institute Inc., Cary, N.C., USA) and S-PLUS® 8.0(Insightful Corp., Seattle, Wash., USA).

Results are shown as point estimates and 95% confidence intervals forthe mean change in HbA1c from baseline [%] after 24 weeks as estimatedby ANCOVA models. The results are given for the whole patient populationof the studies (full analysis set, FAS), for the subpopulation for whichgenetic analyses are performed (full analysis set for pharmacogeneticanalyses, FASG), as well as for the subgroups defined by genotype (CC,CT, TT) of this subpopulation. The numbers of patients for placebocontrol and linagliptin treatment are given in braces.

Point estimates and 95% confidence intervals for the differences inchanges in HbA1c from baseline [%] for the comparison of betweenwild-type homozygous (genotype CC) and heterozygous (genotype CT) orrare homozygous (genotype TT) individuals on linagliptin treatment orcombination treatment (linagliptin+pioglitazone, linagliptin+metformin,linagliptin+metformin+a sulphonylurea) are shown as well. They result ina statistically significant difference between TT and CC (pvalue=0.0192). (Other pairwise comparisons: CT vs. CC: p=0.4359; CT vs.TT: p=0.0712).

This indicates a significant association between the wild-typehomozygous genotype and lower HbA1c on treatment.

EXAMPLES OF FORMULATIONS

The following examples of formulations, which may be obtainedanalogously to methods known in the art, serve to illustrate the presentinvention more fully without restricting it to the contents of theseexamples. The term “active substance” denotes one or more compoundsaccording to the invention, i.e. denotes a DPP-4 inhibitor or a secondor third antidiabetic compound according to this invention or acombination of two or three of said active ingredients, for exampleselected from the combinations as listed in the Table 1 or 2. Additionalsuitable formulations for the DPP-4 inhibitor linagliptin may be thoseformulations disclosed in the application WO 2007/128724, the disclosureof which is incorporated herein in its entirety. Additional suitableformulations for the other DPP-4 inhibitors may be those formulationswhich are available on the market, or formulations described in thepatent applications cited above in paragraph “background of theinvention”, or those described in the literature, for example asdisclosed in current issues of “Rote Liste®” (Germany) or of“Physician's Desk Reference”.

Example 1 Dry Ampoule Containing 75 mg of Active Substance per 10 ml

Composition:

Active substance 75.0 mg Mannitol 50.0 mg water for injections ad 10.0ml

Preparation:

Active substance and mannitol are dissolved in water. After packagingthe solution is freeze-dried. To produce the solution ready for use, theproduct is dissolved in water for injections.

Example 2 Dry Ampoule Containing 35 mg of Active Substance per 2 ml

Composition:

Active substance  35.0 mg Mannitol 100.0 mg water for injections ad 2.0ml

Preparation:

Active substance and mannitol are dissolved in water. After packaging,the solution is freeze-dried.

To produce the solution ready for use, the product is dissolved in waterfor injections.

Example 3 Tablet Containing 50 mg of Active Substance

Composition:

(1) Active substance 50.0 mg (2) Mannitol 98.0 mg (3) Maize starch 50.0mg (4) Polyvinylpyrrolidone 15.0 mg (5) Magnesium stearate  2.0 mg 215.0mg 

Preparation:

(1), (2) and (3) are mixed together and granulated with an aqueoussolution of (4). (5) is added to the dried granulated material. Fromthis mixture tablets are pressed, biplanar, faceted on both sides andwith a dividing notch on one side.

Diameter of the tablets: 9 mm.

Example 4 Tablet Containing 350 mg of Active Substance

Preparation:

(1) Active substance 350.0 mg (2) Mannitol 136.0 mg (3) Maize starch 80.0 mg (4) Polyvinylpyrrolidone  30.0 mg (5) Magnesium stearate  4.0mg 600.0 mg

(1), (2) and (3) are mixed together and granulated with an aqueoussolution of (4). (5) is added to the dried granulated material. Fromthis mixture tablets are pressed, biplanar, faceted on both sides andwith a dividing notch on one side.

Diameter of the tablets: 12 mm.

Example 5 Capsules Containing 50 mg of Active Substance

Composition:

(1) Active substance  50.0 mg (2) Dried maize starch  58.0 mg (3)Mannitol  50.0 mg (4) Magnesium stearate  2.0 mg 160.0 mg

Preparation:

(1) is triturated with (3). This trituration is added to the mixture of(2) and (4) with vigorous mixing. This powder mixture is packed intosize 3 hard gelatin capsules in a capsule filling machine.

Example 6 Capsules Containing 350 mg of Active Substance

Composition:

(1) Active substance 350.0 mg (2) Dried maize starch  46.0 mg (3)Mannitol  30.0 mg (4) Magnesium stearate  4.0 mg 430.0 mg

Preparation:

(1) is triturated with (3). This trituration is added to the mixture of(2) and (4) with vigorous mixing. This powder mixture is packed intosize 0 hard gelatin capsules in a capsule filling machine.

1. A method for improving glycemic control compared with placebo in a type 2 diabetes patient, said method comprising administering linagliptin 5 mg qd for at least 24 weeks, as monotherapy wherein the patient is a drug naïve type 2 diabetes patient, or as add-on combination therapy with metformin wherein the patient is a type 2 diabetes patient with insufficient glycemic control on metformin, or as add-on combination therapy with metformin and a sulfonylurea wherein the patient is a type 2 diabetes patient with insufficient glycemic control on the combination of metformin and a sulfonylurea.
 2. The method according to claim 1, wherein improving glycemic control is reducing HbA1c, FPG and/or PPG.
 3. The method according to claim 1, wherein linagliptin 5 mg qd is administered for at least 24 weeks as monotherapy wherein the patient is a drug naïve type 2 diabetes patient.
 4. The method according to claim 1, wherein linagliptin 5 mg qd is administered for at least 24 weeks as add-on combination therapy with metformin wherein the patient is a type 2 diabetes patient with insufficient glycemic control on metformin.
 5. The method according to claim 1, wherein linagliptin 5 mg qd is administered for at least 24 weeks as add-on combination therapy with metformin and a sulfonylurea wherein the patient is a type 2 diabetes patient with insufficient glycemic control on the combination of metformin and a sulfonylurea.
 6. The method according to claim 1, wherein the patient is of TCF7L2 rs7903146 CC, CT or TT genotype. 